FENTANYL CITRATE 1600ug/1 30 BLISTER PACK per CARTON / 1 LOZENGE per BLISTER PACK (30 BLISTER PACK in 1 CART ) (NDC: 00406921630)
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 |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $796.25 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $796.25 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $796.25 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $796.25 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $796.25 |
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 |
Meridian Prime (HMO)
|
$0.00 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | P | $1,420.94 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $603.81 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $603.81 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $599.23 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $599.23 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $603.81 |
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 Essential (PPO)
|
$15.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:124 /31Days | $796.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:124 /31Days | $796.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:124 /31Days | $796.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:124 /31Days | $796.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:124 /31Days | $796.25 |
Browse Plan Formulary |
HumanaChoice R5826-006 (Regional PPO)
|
$28.20 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $534.89 |
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 Medicare Options Plus (HMO SNP)
|
$28.60 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $1,152.45 |
Browse Plan Formulary |
Fidelis Secure Comfort (HMO SNP)
|
$30.40 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | P Q:29 /30Days | $724.68 |
Browse Plan Formulary |
Meridian Advantage Plan of Michigan (HMO SNP)
|
$31.40 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P | $1,420.94 |
Browse Plan Formulary |
Fidelis Secure Freedom (HMO SNP)
|
$31.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Specialty Tier |
25% | 25% | P Q:29 /30Days | $724.68 |
Browse Plan Formulary |
McLaren Advantage Sapphire (HMO)
|
$36.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
29% | n/a | P Q:120 /30Days | $786.17 |
Browse Plan Formulary |
McLaren Advantage Sapphire (HMO)
|
$36.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
29% | n/a | P Q:120 /30Days | $754.48 |
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 |
BCN Advantage HMO ConnectedCare (HMO)
|
$41.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $796.25 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$55.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | P | $1,249.31 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$58.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | P | $599.23 |
Browse Plan Formulary |
McLaren Advantage Diamond (HMO)
|
$72.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
29% | n/a | P Q:120 /30Days | $786.17 |
Browse Plan Formulary |
McLaren Advantage Diamond (HMO)
|
$72.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
29% | n/a | P Q:120 /30Days | $754.48 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$75.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:124 /31Days | $796.25 |
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)
|
$75.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:124 /31Days | $796.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$75.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:124 /31Days | $796.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$75.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:124 /31Days | $796.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$75.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:124 /31Days | $796.25 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $603.81 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $603.81 |
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 Merit (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $599.23 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $599.23 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $603.81 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$103.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $796.25 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$103.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $796.25 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$103.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $796.25 |
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 |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$103.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $796.25 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$103.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $796.25 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$106.00 |
$100* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$15.00 | $37.50 | P | $1,249.31 |
Browse Plan Formulary |
Alliance Medicare PPO (PPO)
|
$126.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | P | $1,249.31 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$146.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $599.23 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$157.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:124 /31Days | $796.25 |
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 Signature (PPO)
|
$157.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:124 /31Days | $796.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$157.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:124 /31Days | $796.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$157.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:124 /31Days | $796.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$157.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:124 /31Days | $796.25 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$178.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $603.81 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$178.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $603.81 |
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)
|
$178.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $603.81 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$178.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $599.23 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$178.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $599.23 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$192.00 |
$50* |
Yes, but No Gap Coverage for this drug. |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | P | $1,249.31 |
Browse Plan Formulary |
Alliance Medicare PPO (PPO)
|
$210.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
2* |
Non-Preferred Generic |
$10.00 | $25.00 | P | $1,249.31 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$232.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:124 /31Days | $796.25 |
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)
|
$232.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:124 /31Days | $796.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$232.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:124 /31Days | $796.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$232.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:124 /31Days | $796.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$232.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:124 /31Days | $796.25 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$244.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $796.25 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$244.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $796.25 |
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 |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$244.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $796.25 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$244.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $796.25 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$244.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $796.25 |
Browse Plan Formulary |