XENAZINE TABLET 25 MG (112 BOT) (NDC: 67386042201)
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 | 5* |
Specialty Tier |
33% | 33% | P | $5,165.17 |
Browse Plan Formulary |
Advantra (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $4,572.84 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
50% | 50% | P Q:120 /30Days | $5,338.53 |
Browse Plan Formulary |
Amerigroup Medicare-Medicaid Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
0% | 0% | P Q:120 /30Days | $4,551.71 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $4,551.71 |
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 | 5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $4,551.71 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $4,551.71 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $4,551.71 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $4,551.71 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $4,551.71 |
Browse Plan Formulary |
Amerivantage Specialty + Rx (HMO SNP)
|
$0.00 |
$320 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $4,551.71 |
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. | 5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $5,172.83 |
Browse Plan Formulary |
Care Improvement Plus Dual Advantage (Regional PPO SNP)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
$0.00 | $0.00 | P | $5,230.05 |
Browse Plan Formulary |
Care Improvement Plus Gold Rx (PPO SNP)
|
$0.00 |
$315* | No additional gap coverage, only the Donut Hole Discount | 5* |
Specialty Tier |
33% | 33% | P | $5,230.05 |
Browse Plan Formulary |
Care Improvement Plus Gold Rx (Regional PPO SNP)
|
$0.00 |
$315* | No additional gap coverage, only the Donut Hole Discount | 5* |
Specialty Tier |
33% | 33% | P | $5,230.05 |
Browse Plan Formulary |
Care Improvement Plus Silver Rx (Regional PPO SNP)
|
$0.00 |
$307 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | 25% | P | $5,230.05 |
Browse Plan Formulary |
Cigna-HealthSpring Preferred (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | 33% | P Q:120 /30Days | $5,193.39 |
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. | 5 |
Specialty Tier |
33% | 33% | P Q:120 /30Days | $5,193.39 |
Browse Plan Formulary |
Erickson Advantage Guardian (HMO-POS SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | 33% | P | $5,165.17 |
Browse Plan Formulary |
Humana Gold Plus H4510-028 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $5,167.14 |
Browse Plan Formulary |
KelseyCare Advantage Rx (HMO)
|
$0.00 |
$50 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
31% | n/a | P Q:125 /25Days | $4,999.79 |
Browse Plan Formulary |
Memorial Hermann Advantage (HMO)
|
$0.00 |
$100 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
30% | 30% | None | $5,144.98 |
Browse Plan Formulary |
Memorial Hermann Advantage (PPO)
|
$0.00 |
$100 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
30% | 30% | None | $5,144.98 |
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 |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
0% | 0% | P Q:120 /30Days | $5,062.42 |
Browse Plan Formulary |
TexanPlus Choice (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $5,370.74 |
Browse Plan Formulary |
TexanPlus Classic (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $5,370.74 |
Browse Plan Formulary |
UnitedHealthcare Connected (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
0% | 0% | P | $5,165.17 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $5,167.63 |
Browse Plan Formulary |
WellCare Value (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $5,167.63 |
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 R5826-091 (Regional PPO)
|
$15.00 |
$320 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $5,002.64 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$19.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
50% | 50% | P Q:120 /30Days | $5,338.53 |
Browse Plan Formulary |
Care Improvement Plus Medicare Advantage (PPO)
|
$19.00 |
$315* | No additional gap coverage, only the Donut Hole Discount | 5* |
Specialty Tier |
33% | 33% | P | $5,230.05 |
Browse Plan Formulary |
Care Improvement Plus Medicare Advantage (Regional PPO)
|
$19.00 |
$315* | No additional gap coverage, only the Donut Hole Discount | 5* |
Specialty Tier |
33% | 33% | P | $5,230.05 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$21.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $5,167.63 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H4510-021 (HMO SNP)
|
$26.20 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
$0.00 | $0.00 | P Q:120 /30Days | $5,002.64 |
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% | P Q:120 /30Days | $5,193.39 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$27.30 |
$320 | Yes, but No Gap Coverage for this drug. | 4 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $5,062.42 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$27.30 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
15% | 15% | P | $5,165.17 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$27.30 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | P | $5,165.17 |
Browse Plan Formulary |
HumanaChoice R5826-012 (Regional PPO)
|
$34.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $5,002.64 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Choice Plus (PPO)
|
$35.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $5,172.83 |
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 | 5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $4,561.17 |
Browse Plan Formulary |
Erickson Advantage Freedom (HMO-POS)
|
$48.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | 33% | P | $5,230.48 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Choice Premier (PPO)
|
$55.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $5,172.83 |
Browse Plan Formulary |
HumanaChoice H6609-108 (PPO)
|
$66.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $5,002.64 |
Browse Plan Formulary |
KelseyCare Advantage Rx+Choice (HMO-POS)
|
$77.00 |
$50 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
31% | n/a | P Q:125 /25Days | $4,999.79 |
Browse Plan Formulary |
Humana Gold Choice H8145-084 (PFFS)
|
$89.00 |
$200 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
28% | n/a | P Q:120 /30Days | $5,002.64 |
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 Value Plan (PPO)
|
$92.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
50% | 50% | P Q:120 /30Days | $5,338.53 |
Browse Plan Formulary |
Aetna Medicare Select Plus Plan (PPO)
|
$139.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $5,101.38 |
Browse Plan Formulary |
Erickson Advantage Champion (HMO-POS SNP)
|
$189.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | 33% | P | $5,230.48 |
Browse Plan Formulary |
Erickson Advantage Signature with Drugs (HMO-POS)
|
$189.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | 33% | P | $5,230.48 |
Browse Plan Formulary |
KelseyCare Advantage Rx Premier (HMO)
|
$221.00 |
$50 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
30% | n/a | P Q:125 /25Days | $4,999.79 |
Browse Plan Formulary |