SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE (60 TABLET, FILM COATED in ) (NDC: 49702022418)
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 |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | None | $1,236.67 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | None | $1,230.14 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | None | $1,221.71 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | None | $1,274.94 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | None | $1,222.91 |
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 |
Meridian Prime (HMO)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | None | $1,231.34 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | None | $1,223.27 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | None | $1,230.79 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | None | $1,229.38 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | None | $1,235.59 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | None | $1,241.06 |
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 |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | None | $1,235.73 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | None | $1,230.14 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | None | $1,227.70 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | None | $1,238.08 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | None | $1,222.91 |
Browse Plan Formulary |
HumanaChoice R5826-006 (Regional PPO)
|
$28.20 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | Q:120 /30Days | $1,219.05 |
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 |
BCN Advantage HMO MyChoice Wellness (HMO)
|
$29.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,238.08 |
Browse Plan Formulary |
Fidelis Secure Comfort (HMO SNP)
|
$30.40 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | None | $1,230.88 |
Browse Plan Formulary |
Meridian Advantage Plan of Michigan (HMO SNP)
|
$31.40 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $1,231.34 |
Browse Plan Formulary |
Fidelis Secure Freedom (HMO SNP)
|
$31.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Specialty Tier |
25% | 25% | None | $1,230.88 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$39.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | None | $1,223.27 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | None | $1,222.91 |
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 |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | None | $1,235.73 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | None | $1,230.14 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | None | $1,227.70 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | None | $1,238.08 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$55.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $1,230.79 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$55.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $1,229.38 |
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 |
PriorityMedicare Merit (PPO)
|
$55.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $1,235.59 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$55.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $1,241.06 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$55.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $1,223.27 |
Browse Plan Formulary |
HumanaChoice H5216-010 (PPO)
|
$57.00 |
$320 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | Q:120 /30Days | $1,216.29 |
Browse Plan Formulary |
Humana Gold Choice H8145-005 (PFFS)
|
$83.00 |
$320 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | Q:120 /30Days | $1,216.23 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$91.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,274.94 |
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 |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$91.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,222.91 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$91.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,236.67 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$91.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,230.14 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$91.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,221.71 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$110.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | None | $1,238.08 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$110.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | None | $1,222.91 |
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 |
Medicare Plus Blue PPO Signature (PPO)
|
$110.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | None | $1,235.73 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$110.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | None | $1,230.14 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$110.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | None | $1,227.70 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$114.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $1,223.27 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$131.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $1,241.06 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$131.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $1,223.27 |
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 |
PriorityMedicare Select (PPO)
|
$131.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $1,230.79 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$131.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $1,229.38 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$131.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $1,235.59 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$182.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,227.70 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$182.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,238.08 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$182.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,222.91 |
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 |
Medicare Plus Blue PPO Assure (PPO)
|
$182.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,235.73 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$182.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,230.14 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$196.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,222.91 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$196.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,230.14 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$196.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,236.67 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$196.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,221.71 |
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 |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$196.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,274.94 |
Browse Plan Formulary |