TIKOSYN .250MG CAPSULE (60 BOT) (NDC: 00069581060)
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 Northern Pennsylvania Gold (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
50% | 50% | None | $338.46 |
Browse Plan Formulary |
Advantra Silver (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
50% | 50% | None | $338.65 |
Browse Plan Formulary |
Advantra Silver (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
50% | 50% | None | $338.75 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$39.00 | $117.00 | None | $331.09 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$39.00 | $117.00 | None | $329.73 |
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. | 3 |
Preferred Brand |
$39.00 | $117.00 | None | $329.71 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$39.00 | $117.00 | None | $329.61 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$39.00 | $117.00 | None | $331.01 |
Browse Plan Formulary |
UPMC for Life HMO Deductible with Rx (HMO)
|
$18.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$45.00 | $112.50 | None | $336.67 |
Browse Plan Formulary |
AdvantraOne (PPO)
|
$29.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
50% | 50% | None | $338.44 |
Browse Plan Formulary |
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 | None | $340.27 |
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 |
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 | None | $340.27 |
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% | None | $330.21 |
Browse Plan Formulary |
UPMC Community Care (HMO SNP)
|
$33.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $336.71 |
Browse Plan Formulary |
UPMC for You Advantage (HMO SNP)
|
$33.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$35.00 | $105.00 | None | $336.67 |
Browse Plan Formulary |
HumanaChoice H5525-006 (PPO)
|
$34.00 |
$320 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:120 /30Days | $332.58 |
Browse Plan Formulary |
UPMC for Life PPO High Deductible with Rx (PPO)
|
$39.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$45.00 | $112.50 | None | $336.67 |
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 R5826-002 (Regional PPO)
|
$39.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:120 /30Days | $332.82 |
Browse Plan Formulary |
Security Blue ValueRx (HMO)
|
$42.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $343.84 |
Browse Plan Formulary |
Gateway Health Medicare Assured Gold (HMO SNP)
|
$46.30 |
$0 | No additional gap coverage, only the Donut Hole Discount | 6 |
Select Care Drugs |
$10.00 | $20.00 | None | $340.27 |
Browse Plan Formulary |
Advantra Silver Plus (HMO)
|
$49.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
50% | 50% | None | $338.76 |
Browse Plan Formulary |
Advantra Silver Plus (PPO)
|
$67.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
50% | 50% | None | $338.64 |
Browse Plan Formulary |
Gateway Health Medicare Assured Platinum (HMO SNP)
|
$77.80 |
$0 | No additional gap coverage, only the Donut Hole Discount | 6 |
Select Care Drugs |
$10.00 | $20.00 | None | $340.27 |
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 |
UPMC for Life HMO Rx (HMO)
|
$78.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$45.00 | $112.50 | None | $336.67 |
Browse Plan Formulary |
Freedom Blue PPO ValueRx (PPO)
|
$105.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $343.84 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$116.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
50% | 50% | None | $338.75 |
Browse Plan Formulary |
Geisinger Gold Preferred Select Rx (PPO)
|
$119.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$39.00 | $117.00 | None | $331.01 |
Browse Plan Formulary |
Geisinger Gold Preferred Select Rx (PPO)
|
$119.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$39.00 | $117.00 | None | $329.61 |
Browse Plan Formulary |
Geisinger Gold Preferred Select Rx (PPO)
|
$119.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$39.00 | $117.00 | None | $331.09 |
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)
|
$129.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$39.00 | $117.00 | None | $329.73 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$129.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$39.00 | $117.00 | None | $331.01 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$129.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$39.00 | $117.00 | None | $329.61 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$129.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$39.00 | $117.00 | None | $329.71 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$129.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$39.00 | $117.00 | None | $331.09 |
Browse Plan Formulary |
Freedom Blue PPO Select (PPO)
|
$137.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $343.84 |
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 |
UPMC for Life PPO Rx Enhanced (PPO)
|
$139.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$45.00 | $112.50 | None | $336.67 |
Browse Plan Formulary |
Security Blue Standard (HMO)
|
$201.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $343.84 |
Browse Plan Formulary |
UPMC for Life HMO Rx Enhanced (HMO)
|
$223.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$45.00 | $112.50 | None | $336.67 |
Browse Plan Formulary |
Security Blue Deluxe (HMO)
|
$237.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $105.00 | None | $343.84 |
Browse Plan Formulary |
Freedom Blue PPO Classic (PPO)
|
$280.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $343.84 |
Browse Plan Formulary |