Sumatriptan Succinate 25mg/1 9 BLISTER PACK per CARTON / 9 TABLET per BLISTER PACK (9 BLISTER PACK in 1 CARTO ) (NDC: 55111029109)
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 |
Advantra Silver (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:9 /30Days | $24.29 |
Browse Plan Formulary |
Advantra Silver (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:9 /30Days | $23.87 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$20.00 | $60.00 | Q:16 /28Days | $7.68 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$20.00 | $60.00 | Q:16 /28Days | $7.68 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$20.00 | $60.00 | Q:16 /28Days | $8.11 |
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 |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$20.00 | $60.00 | Q:16 /28Days | $7.68 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$20.00 | $60.00 | Q:16 /28Days | $7.68 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$20.00 | $60.00 | Q:16 /28Days | $8.11 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$20.00 | $60.00 | Q:16 /28Days | $7.68 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO-POS SNP)
|
$32.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | None | $8.82 |
Browse Plan Formulary |
Advantra Cares (HMO SNP)
|
$33.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:9 /30Days | $7.93 |
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 |
Gateway Health Medicare Assured Diamond (HMO SNP)
|
$33.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | n/a | Q:18 /30Days | $11.78 |
Browse Plan Formulary |
Gateway Health Medicare Assured Ruby (HMO SNP)
|
$33.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | Q:18 /30Days | $11.78 |
Browse Plan Formulary |
Geisinger Gold Secure Rx (HMO SNP)
|
$33.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:16 /28Days | $7.81 |
Browse Plan Formulary |
HumanaChoice H5525-006 (PPO)
|
$34.00 |
$320* |
Yes, but No Gap Coverage for this drug. |
2* |
Non-Preferred Generic |
$18.00 | $0.00 | Q:9 /30Days | $14.87 |
Browse Plan Formulary |
HumanaChoice R5826-002 (Regional PPO)
|
$39.90 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$18.00 | $0.00 | Q:9 /30Days | $14.87 |
Browse Plan Formulary |
Gateway Health Medicare Assured Gold (HMO SNP)
|
$46.30 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:18 /30Days | $11.78 |
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 Silver Plus (HMO)
|
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:9 /30Days | $23.82 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (HMO)
|
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:9 /30Days | $29.01 |
Browse Plan Formulary |
Humana Gold Choice H8145-052 (PFFS)
|
$62.00 |
$320* |
Yes, but No Gap Coverage for this drug. |
2* |
Non-Preferred Generic |
$18.00 | $0.00 | Q:9 /30Days | $14.87 |
Browse Plan Formulary |
Advantra Silver Plus (PPO)
|
$67.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:9 /30Days | $23.81 |
Browse Plan Formulary |
Freedom Blue PPO HD Rx (PPO)
|
$70.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$12.00 | $30.00 | Q:36 /31Days | $17.51 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$70.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | Q:16 /28Days | $8.11 |
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 |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$70.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | Q:16 /28Days | $7.68 |
Browse Plan Formulary |
SeniorBlue - Option 2 (PPO)
|
$72.40 |
$0 |
to be determined |
2 |
Tier 2 |
$17.00 | $51.00 | Q:9 /30Days | $22.15 |
Browse Plan Formulary |
Gateway Health Medicare Assured Platinum (HMO SNP)
|
$77.80 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:18 /30Days | $11.78 |
Browse Plan Formulary |
Freedom Blue PPO ValueRx (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$12.00 | $30.00 | Q:36 /31Days | $17.51 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$116.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:9 /30Days | $23.87 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$124.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:9 /30Days | $28.95 |
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 |
Geisinger Gold Classic Advantage Rx (HMO)
|
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | Q:16 /28Days | $7.68 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | Q:16 /28Days | $7.68 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | Q:16 /28Days | $7.68 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | Q:16 /28Days | $8.11 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | Q:16 /28Days | $7.68 |
Browse Plan Formulary |
Aetna Medicare Select Plus Plan (PPO)
|
$139.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:9 /30Days | $29.02 |
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 |
SeniorBlue - Option 1 (PPO)
|
$191.90 |
$0 |
to be determined |
2 |
Tier 2 |
$10.00 | $30.00 | Q:9 /30Days | $22.15 |
Browse Plan Formulary |
Freedom Blue PPO Standard (PPO)
|
$246.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$12.00 | $30.00 | Q:36 /31Days | $17.51 |
Browse Plan Formulary |
Freedom Blue PPO Deluxe (PPO)
|
$296.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$12.00 | $30.00 | Q:36 /31Days | $17.51 |
Browse Plan Formulary |