SYNTHROID 88 MCG TABLET (1000 BOT) (NDC: 00074659419)
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 |
PriorityMedicare Value (HMO-POS)
|
$7.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $31.95 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $31.95 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $32.07 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $31.85 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $31.88 |
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 |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $31.91 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $31.93 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $31.93 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $31.83 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $31.87 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $31.97 |
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 R5826-006 (Regional PPO)
|
$28.20 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | None | $31.78 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$30.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $32.07 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$30.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $31.85 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$30.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $31.88 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$30.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $31.91 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$30.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $31.95 |
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 |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $31.97 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $31.93 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $31.93 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $31.83 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $31.87 |
Browse Plan Formulary |
HumanaChoice H5216-009 (PPO)
|
$67.00 |
$320* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$45.00 | $125.00 | None | $31.87 |
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 H8145-005 (PFFS)
|
$83.00 |
$320* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$45.00 | $125.00 | None | $31.81 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$85.00 | $212.50 | None | $31.95 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$109.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$85.00 | $212.50 | None | $31.91 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$109.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$85.00 | $212.50 | None | $31.95 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$109.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$85.00 | $212.50 | None | $32.07 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$109.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$85.00 | $212.50 | None | $31.85 |
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 |
PriorityMedicare Select (PPO)
|
$109.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$85.00 | $212.50 | None | $31.88 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$110.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $31.87 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$110.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $31.97 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$110.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $31.93 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$110.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $31.93 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$110.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $31.83 |
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 |
Medicare Plus Blue PPO Assure (PPO)
|
$182.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $31.83 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$182.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $31.93 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$182.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $31.87 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$182.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $31.97 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$182.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $31.93 |
Browse Plan Formulary |