XARELTO 10mg/1 10 BLISTER PACK per CARTON / 10 TABLET per BLISTER PACK (10 BLISTER PACK in 1 CART ) (NDC: 50458058010)
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:30 /30Days | $343.20 |
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:30 /30Days | $343.24 |
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 | Q:30 /1Days | $333.06 |
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 | Q:30 /1Days | $334.47 |
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 | Q:30 /1Days | $334.02 |
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 |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$39.00 | $117.00 | Q:30 /1Days | $339.53 |
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 | Q:30 /1Days | $334.51 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$39.00 | $117.00 | Q:30 /1Days | $339.57 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$39.00 | $117.00 | Q:30 /1Days | $334.05 |
Browse Plan Formulary |
Humana Gold Plus H6859-001 (HMO)
|
$0.00 |
$200* | Yes, but No Gap Coverage for this drug. | 3* |
Preferred Brand |
$45.00 | $125.00 | Q:35 /60Days | $336.44 |
Browse Plan Formulary |
UPMC for Life HMO Deductible with Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$45.00 | $112.50 | Q:60 /365Days | $338.05 |
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 |
Cigna-HealthSpring TotalCare (HMO SNP)
|
$25.40 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $339.24 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$27.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | P Q:30 /30Days | $338.50 |
Browse Plan Formulary |
Cigna-HealthSpring Achieve (HMO SNP)
|
$28.50 |
$280 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $339.24 |
Browse Plan Formulary |
AdvantraOne (PPO)
|
$29.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $343.05 |
Browse Plan Formulary |
Cigna-HealthSpring Preferred (HMO)
|
$29.50 |
$280 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $338.99 |
Browse Plan Formulary |
Cigna-HealthSpring Preferred (HMO)
|
$29.50 |
$280 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $339.19 |
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 Cares (HMO SNP)
|
$33.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | Q:30 /30Days | $340.85 |
Browse Plan Formulary |
AmeriHealth VIP Care (HMO SNP)
|
$33.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $338.96 |
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 | $343.49 |
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 | None | $343.49 |
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:30 /1Days | $335.33 |
Browse Plan Formulary |
HumanaChoice H5525-006 (PPO)
|
$34.00 |
$320* | Yes, but No Gap Coverage for this drug. | 3* |
Preferred Brand |
$45.00 | $125.00 | Q:35 /60Days | $336.00 |
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 High Deductible with Rx (PPO)
|
$39.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$45.00 | $112.50 | Q:60 /365Days | $338.05 |
Browse Plan Formulary |
HumanaChoice R5826-002 (Regional PPO)
|
$39.90 |
$320* | No additional gap coverage, only the Donut Hole Discount | 3* |
Preferred Brand |
$45.00 | $125.00 | Q:35 /60Days | $335.87 |
Browse Plan Formulary |
Gateway Health Medicare Assured Gold (HMO SNP)
|
$46.30 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $90.00 | None | $343.49 |
Browse Plan Formulary |
Advantra Silver Plus (HMO)
|
$49.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $343.21 |
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:30 /30Days | $340.91 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (PPO)
|
$49.00 |
$230 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $125.00 | P Q:30 /30Days | $338.22 |
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 Choice H8145-052 (PFFS)
|
$62.00 |
$320* | Yes, but No Gap Coverage for this drug. | 3* |
Preferred Brand |
$45.00 | $125.00 | Q:35 /60Days | $335.88 |
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:30 /30Days | $343.21 |
Browse Plan Formulary |
Freedom Blue PPO HD Rx (PPO)
|
$70.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $346.96 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$70.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$39.00 | $117.00 | Q:30 /1Days | $339.57 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$70.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$39.00 | $117.00 | Q:30 /1Days | $334.05 |
Browse Plan Formulary |
SeniorBlue - Option 2 (PPO)
|
$72.40 |
$0 | to be determined | 3 |
Tier 3 |
$38.00 | $114.00 | None | $341.04 |
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 Platinum (HMO SNP)
|
$77.80 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $90.00 | None | $343.49 |
Browse Plan Formulary |
Freedom Blue PPO ValueRx (PPO)
|
$95.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $346.96 |
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:30 /30Days | $343.24 |
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:30 /30Days | $340.91 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$124.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$39.00 | $117.00 | Q:30 /1Days | $334.51 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$124.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$39.00 | $117.00 | Q:30 /1Days | $339.53 |
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. | 3 |
Preferred Brand |
$39.00 | $117.00 | Q:30 /1Days | $334.02 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$124.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$39.00 | $117.00 | Q:30 /1Days | $334.47 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$124.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$39.00 | $117.00 | Q:30 /1Days | $333.06 |
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:30 /30Days | $340.91 |
Browse Plan Formulary |
SeniorBlue - Option 1 (PPO)
|
$191.90 |
$0 | to be determined | 3 |
Tier 3 |
$38.00 | $114.00 | None | $341.04 |
Browse Plan Formulary |
Freedom Blue PPO Standard (PPO)
|
$246.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $346.96 |
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 |
Freedom Blue PPO Deluxe (PPO)
|
$296.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $346.96 |
Browse Plan Formulary |