TIKOSYN .125MG CAPSULE (60 BOT) (NDC: 00069580060)
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 |
$220 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $333.41 |
Browse Plan Formulary |
AARP MedicareComplete Choice Plan 2 (Regional PPO)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $333.09 |
Browse Plan Formulary |
BlueMedicare HMO LifeTime (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $337.94 |
Browse Plan Formulary |
BlueMedicare HMO MyTime (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$80.00 | $240.00 | None | $337.62 |
Browse Plan Formulary |
Freedom Medicare Plan Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | None | $344.76 |
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 |
Freedom VIP Care (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Brand |
$75.00 | $150.00 | None | $344.79 |
Browse Plan Formulary |
Freedom VIP Savings (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None | $344.79 |
Browse Plan Formulary |
Freedom VIP Savings COPD (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None | $344.79 |
Browse Plan Formulary |
Humana Gold Plus - Diabetes (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$60.00 | $170.00 | Q:240 /30Days | $334.55 |
Browse Plan Formulary |
Humana Gold Plus H1036-067 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$55.00 | $155.00 | Q:240 /30Days | $334.88 |
Browse Plan Formulary |
Humana Gold Plus H1036-141 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:240 /30Days | $334.55 |
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 |
HumanaChoice R5826-074 (Regional PPO)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:240 /30Days | $334.57 |
Browse Plan Formulary |
Optimum Diamond Rewards (HMO-POS SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | None | $345.48 |
Browse Plan Formulary |
Optimum Diamond Rewards COPD (HMO-POS SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | None | $345.48 |
Browse Plan Formulary |
Optimum Gold Plus Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | None | $347.39 |
Browse Plan Formulary |
Optimum Gold Rewards Plan (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None | $345.68 |
Browse Plan Formulary |
Optimum Platinum Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | None | $345.68 |
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 |
Preferred Secure Option (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $333.44 |
Browse Plan Formulary |
Ultimate Premier (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Brand |
$50.00 | $100.00 | None | $338.30 |
Browse Plan Formulary |
Ultimate Premier Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Brand |
$45.00 | $90.00 | None | $338.30 |
Browse Plan Formulary |
WellCare Dividend (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$75.00 | $187.50 | None | $344.80 |
Browse Plan Formulary |
WellCare Essential (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$60.00 | $150.00 | None | $344.76 |
Browse Plan Formulary |
WellCare Value (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$55.00 | $137.50 | None | $344.79 |
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 SNP-DE H1036-102 (HMO SNP)
|
$15.20 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:240 /30Days | $334.69 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$17.70 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None | $343.66 |
Browse Plan Formulary |
WellCare Liberty (HMO SNP)
|
$18.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None | $343.66 |
Browse Plan Formulary |
WellCare Select (HMO SNP)
|
$19.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None | $343.53 |
Browse Plan Formulary |
BlueMedicare Regional PPO (Regional PPO)
|
$20.20 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $337.93 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete LP (HMO SNP)
|
$24.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $333.44 |
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 |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$24.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $333.23 |
Browse Plan Formulary |
Freedom Medi-Medi Full (HMO SNP)
|
$25.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $345.08 |
Browse Plan Formulary |
Freedom Medi-Medi Partial (HMO SNP)
|
$25.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $345.08 |
Browse Plan Formulary |
Optimum Emerald Full (HMO SNP)
|
$25.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None | $345.00 |
Browse Plan Formulary |
Optimum Emerald Partial (HMO SNP)
|
$25.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None | $345.00 |
Browse Plan Formulary |
Sunshine Health Advantage (HMO SNP)
|
$25.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$45.00 | $45.00 | Q:60 /30Days | $343.96 |
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 |
UnitedHealthcare Dual Complete RP (Regional PPO SNP)
|
$25.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $333.09 |
Browse Plan Formulary |
AARP MedicareComplete Choice (PPO)
|
$29.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $333.63 |
Browse Plan Formulary |
HumanaChoice R5826-005 (Regional PPO)
|
$39.40 |
$100 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $245.00 | Q:240 /30Days | $334.57 |
Browse Plan Formulary |
Humana Gold Choice H8145-061 (PFFS)
|
$101.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:240 /30Days | $334.35 |
Browse Plan Formulary |
BlueMedicare PPO (PPO)
|
$127.10 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$75.00 | $225.00 | None | $337.93 |
Browse Plan Formulary |