TRADJENTA 5mg/1 90 FILM COATED TABLETS in BOTTLE (90 TABLET, FILM COATED in ) (NDC: 00597014090)
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 | $333.45 |
Browse Plan Formulary |
Advantra (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | None | $339.16 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | None | $338.26 |
Browse Plan Formulary |
Amerigroup Medicare-Medicaid Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | Q:30 /30Days | $336.30 |
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:30 /30Days | $337.14 |
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:30 /30Days | $336.94 |
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:30 /30Days | $336.06 |
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:30 /30Days | $335.83 |
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:30 /30Days | $337.30 |
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:30 /30Days | $335.63 |
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:30 /30Days | $336.17 |
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 |
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 | $339.00 |
Browse Plan Formulary |
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 | $333.75 |
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 | $333.62 |
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 | $333.75 |
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 | $333.75 |
Browse Plan Formulary |
Cigna-HealthSpring Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:30 /30Days | $335.38 |
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 |
Cigna-HealthSpring Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | $90.00 | Q:30 /30Days | $336.43 |
Browse Plan Formulary |
Erickson Advantage Guardian (HMO-POS SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days | $333.60 |
Browse Plan Formulary |
Humana Gold Plus H4510-028 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $110.00 | Q:30 /30Days | $335.34 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | Q:30 /30Days | $336.20 |
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 | $336.23 |
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 | $336.23 |
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 |
UnitedHealthcare Connected (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | Q:30 /30Days | $333.47 |
Browse Plan Formulary |
HumanaChoice R5826-091 (Regional PPO)
|
$15.00 |
$320* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days | $334.53 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$19.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | None | $338.26 |
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 | $333.62 |
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 | $333.75 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H4510-021 (HMO SNP)
|
$26.20 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:30 /30Days | $335.27 |
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 |
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 | $336.36 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$27.30 |
$320 |
Yes, but No Gap Coverage for this drug. |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $336.21 |
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 | $333.50 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$27.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | Q:30 /30Days | $333.47 |
Browse Plan Formulary |
HumanaChoice R5826-012 (Regional PPO)
|
$34.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days | $334.53 |
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 | $339.03 |
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 |
3 |
Tier 3 |
25% | 25% | None | $339.13 |
Browse Plan Formulary |
Erickson Advantage Freedom (HMO-POS)
|
$48.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$85.00 | $245.00 | Q:30 /30Days | $333.92 |
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 | $339.03 |
Browse Plan Formulary |
HumanaChoice H6609-108 (PPO)
|
$66.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days | $334.72 |
Browse Plan Formulary |
Humana Gold Choice H8145-084 (PFFS)
|
$89.00 |
$200* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days | $334.66 |
Browse Plan Formulary |
Aetna Medicare Value Plan (PPO)
|
$92.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | None | $338.26 |
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. |
3 |
Preferred Brand |
$45.00 | $112.50 | None | $338.26 |
Browse Plan Formulary |
Erickson Advantage Champion (HMO-POS SNP)
|
$189.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$85.00 | $245.00 | Q:30 /30Days | $333.92 |
Browse Plan Formulary |
Erickson Advantage Signature with Drugs (HMO-POS)
|
$189.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$85.00 | $245.00 | Q:30 /30Days | $333.92 |
Browse Plan Formulary |