Pristiq Extended-Release 50mg/1 30 TABLET, EXTENDED RELEASE in 1 BOTTLE, PLASTIC (30 TABLET, EXTENDED RELEA ) (NDC: 00008121130)
2015 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
Plan Name |
Monthly Prem. |
De- duct- ible | Does Plan Offer Additional Gap Coverage | Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Plan’s Avg. Retail Drug Price 30-Day |
Tier Nbr. |
Tier Desc. |
30-Day Prfrd. Pharm |
90-Day Mail Order |
AARP MedicareComplete (HMO)
|
$0.00 |
$165 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:30 /30Days | $255.86 |
Browse Plan Formulary |
Advantra (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
50% | 50% | S Q:30 /30Days | $260.26 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
50% | 50% | S Q:30 /30Days | $259.49 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:240 /30Days | $259.55 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:240 /30Days | $258.38 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:240 /30Days | $259.28 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:240 /30Days | $259.17 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:240 /30Days | $258.77 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:240 /30Days | $258.08 |
Browse Plan Formulary |
Amerivantage Specialty + Rx (HMO SNP)
|
$0.00 |
$320 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:240 /30Days | $258.74 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Basic (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$85.00 | $285.00 | Q:30 /30Days | $260.25 |
Browse Plan Formulary |
|
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Care Improvement Plus Dual Advantage (Regional PPO SNP)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | Q:30 /30Days | $256.24 |
Browse Plan Formulary |
Care Improvement Plus Gold Rx (PPO SNP)
|
$0.00 |
$315 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:30 /30Days | $256.18 |
Browse Plan Formulary |
Care Improvement Plus Gold Rx (Regional PPO SNP)
|
$0.00 |
$315 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:30 /30Days | $256.24 |
Browse Plan Formulary |
Care Improvement Plus Silver Rx (Regional PPO SNP)
|
$0.00 |
$307 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
25% | 25% | Q:30 /30Days | $256.24 |
Browse Plan Formulary |
Cigna-HealthSpring Preferred (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$60.00 | $180.00 | Q:30 /30Days | $258.32 |
Browse Plan Formulary |
Cigna-HealthSpring Preferred (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$60.00 | $180.00 | Q:30 /30Days | $257.23 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Plus H4510-028 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$85.00 | $245.00 | Q:30 /30Days | $257.73 |
Browse Plan Formulary |
KelseyCare Advantage Rx (HMO)
|
$0.00 |
$50 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | n/a | Q:30 /30Days | $257.99 |
Browse Plan Formulary |
Memorial Hermann Advantage (HMO)
|
$0.00 |
$100 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$85.00 | $170.00 | None | $259.60 |
Browse Plan Formulary |
Memorial Hermann Advantage (PPO)
|
$0.00 |
$100 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$85.00 | $170.00 | None | $259.60 |
Browse Plan Formulary |
TexanPlus Choice (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $40.00 | Q:30 /30Days | $257.96 |
Browse Plan Formulary |
TexanPlus Classic (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $40.00 | Q:30 /30Days | $257.96 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
WellCare Dividend (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$75.00 | $187.50 | P Q:30 /30Days | $264.09 |
Browse Plan Formulary |
WellCare Value (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$75.00 | $187.50 | P Q:30 /30Days | $264.09 |
Browse Plan Formulary |
HumanaChoice R5826-091 (Regional PPO)
|
$15.00 |
$320 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:30 /30Days | $257.01 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$19.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
50% | 50% | S Q:30 /30Days | $259.49 |
Browse Plan Formulary |
Care Improvement Plus Medicare Advantage (PPO)
|
$19.00 |
$315 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:30 /30Days | $256.18 |
Browse Plan Formulary |
Care Improvement Plus Medicare Advantage (Regional PPO)
|
$19.00 |
$315 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:30 /30Days | $256.24 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
WellCare Access (HMO SNP)
|
$21.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$90.00 | $225.00 | P Q:30 /30Days | $263.99 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H4510-021 (HMO SNP)
|
$26.20 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | Q:30 /30Days | $257.36 |
Browse Plan Formulary |
Cigna-HealthSpring TotalCare (HMO SNP)
|
$27.30 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $258.25 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$27.30 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | Q:30 /30Days | $256.10 |
Browse Plan Formulary |
HumanaChoice R5826-012 (Regional PPO)
|
$34.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:30 /30Days | $257.01 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Choice Plus (PPO)
|
$35.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$85.00 | $285.00 | Q:30 /30Days | $260.31 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Advantra (PPO)
|
$41.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | S Q:30 /30Days | $260.17 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Choice Premier (PPO)
|
$55.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$85.00 | $285.00 | Q:30 /30Days | $260.31 |
Browse Plan Formulary |
HumanaChoice H6609-108 (PPO)
|
$66.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:30 /30Days | $256.95 |
Browse Plan Formulary |
KelseyCare Advantage Rx+Choice (HMO-POS)
|
$77.00 |
$50 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | n/a | Q:30 /30Days | $257.99 |
Browse Plan Formulary |
Humana Gold Choice H8145-084 (PFFS)
|
$89.00 |
$200 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:30 /30Days | $257.19 |
Browse Plan Formulary |
Aetna Medicare Value Plan (PPO)
|
$92.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
50% | 50% | S Q:30 /30Days | $259.49 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Aetna Medicare Select Plus Plan (PPO)
|
$139.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
50% | 50% | S Q:30 /30Days | $259.49 |
Browse Plan Formulary |
KelseyCare Advantage Rx Premier (HMO)
|
$221.00 |
$50 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$20.00 | n/a | Q:30 /30Days | $257.99 |
Browse Plan Formulary |