ZOLPIDEM TARTRATE 10MG TABLETS [Ambien, Edluar, Zolpimist] (1000 BOTPL) (NDC: 00603646932)
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 |
Commonwealth Care Alliance (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic Drugs |
0% | 0% | Q:30 /30Days | $2.37 |
Browse Plan Formulary |
Fallon Senior Plan Super Saver Rx (HMO)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$5.00 | $15.00 | Q:30 /30Days | $3.00 |
Browse Plan Formulary |
Fallon Senior Plan Super Saver Rx (HMO)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$5.00 | $15.00 | Q:30 /30Days | $3.00 |
Browse Plan Formulary |
Fallon Senior Plan Super Saver Rx (HMO)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$5.00 | $15.00 | Q:30 /30Days | $3.00 |
Browse Plan Formulary |
Fallon Senior Plan Super Saver Rx (HMO)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$5.00 | $15.00 | Q:30 /30Days | $3.00 |
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 |
Fallon Senior Plan Super Saver Rx (HMO)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$5.00 | $15.00 | Q:30 /30Days | $3.00 |
Browse Plan Formulary |
Medicare PPO Blue SaverRx (PPO)
|
$0.00 |
$320* | No additional gap coverage, only the Donut Hole Discount | 2* |
Non-Preferred Generic |
$12.00 | $24.00 | Q:30 /30Days | $7.91 |
Browse Plan Formulary |
Tufts Health Unify (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic Drugs |
0% | 0% | Q:30 /30Days | $1.73 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Saver Rx (HMO)
|
$0.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Non-Preferred Generic |
$12.00 | $30.00 | Q:30 /30Days | $1.73 |
Browse Plan Formulary |
Erickson Advantage Guardian (HMO-POS SNP)
|
$2.90 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$70.00 | $200.00 | Q:90 /365Days | $27.72 |
Browse Plan Formulary |
UnitedHealthcare Senior Care Options (HMO SNP)
|
$22.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | Q:90 /365Days | $25.97 |
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 |
Medicare HMO Blue ValueRx (HMO)
|
$27.00 |
$320* | No additional gap coverage, only the Donut Hole Discount | 2* |
Non-Preferred Generic |
$8.00 | $16.00 | Q:30 /30Days | $7.91 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$28.30 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | Q:90 /365Days | $25.97 |
Browse Plan Formulary |
Senior Care Options Program (HMO SNP)
|
$29.60 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | P Q:30 /30Days | $2.39 |
Browse Plan Formulary |
Tufts Health Plan Senior Care Options (HMO SNP)
|
$29.60 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | Q:30 /30Days | $1.73 |
Browse Plan Formulary |
NaviCare (HMO SNP)
|
$29.70 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
25% | 25% | Q:30 /30Days | $2.46 |
Browse Plan Formulary |
Senior Whole Health (HMO SNP)
|
$29.70 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | S Q:30 /30Days | $9.53 |
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 |
Senior Whole Health NHC (HMO SNP)
|
$29.70 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | S Q:30 /30Days | $9.53 |
Browse Plan Formulary |
AARP MedicareComplete Choice (Regional PPO)
|
$29.90 |
$255 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:90 /365Days | $25.91 |
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:90 /365Days | $29.22 |
Browse Plan Formulary |
Medicare PPO Blue ValueRx (PPO)
|
$49.00 |
$320* | No additional gap coverage, only the Donut Hole Discount | 2* |
Non-Preferred Generic |
$8.00 | $16.00 | Q:30 /30Days | $7.91 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$55.90 |
$150* | No additional gap coverage, only the Donut Hole Discount | 2* |
Non-Preferred Generic |
$8.00 | $21.00 | Q:30 /30Days | $1.73 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$55.90 |
$150* | No additional gap coverage, only the Donut Hole Discount | 2* |
Non-Preferred Generic |
$8.00 | $21.00 | Q:30 /30Days | $1.73 |
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 |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$55.90 |
$150* | No additional gap coverage, only the Donut Hole Discount | 2* |
Non-Preferred Generic |
$8.00 | $21.00 | Q:30 /30Days | $1.73 |
Browse Plan Formulary |
Fallon Senior Plan Saver Enhanced RX (HMO)
|
$56.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$5.00 | $15.00 | Q:30 /30Days | $3.00 |
Browse Plan Formulary |
Fallon Senior Plan Saver Enhanced RX (HMO)
|
$56.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$5.00 | $15.00 | Q:30 /30Days | $3.00 |
Browse Plan Formulary |
Fallon Senior Plan Saver Enhanced RX (HMO)
|
$56.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$5.00 | $15.00 | Q:30 /30Days | $3.00 |
Browse Plan Formulary |
Fallon Senior Plan Saver Enhanced RX (HMO)
|
$56.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$5.00 | $15.00 | Q:30 /30Days | $3.00 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$141.30 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$8.00 | $21.00 | Q:30 /30Days | $1.73 |
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 |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$141.30 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$8.00 | $21.00 | Q:30 /30Days | $1.73 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$141.30 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$8.00 | $21.00 | Q:30 /30Days | $1.73 |
Browse Plan Formulary |
Medicare PPO Blue PlusRx (PPO)
|
$153.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Non-Preferred Generic |
$6.00 | $12.00 | Q:30 /30Days | $7.91 |
Browse Plan Formulary |
Fallon Senior Plan Plus Enhanced RX (HMO)
|
$166.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$5.00 | $15.00 | Q:30 /30Days | $3.00 |
Browse Plan Formulary |
Fallon Senior Plan Plus Enhanced RX (HMO)
|
$166.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$5.00 | $15.00 | Q:30 /30Days | $3.00 |
Browse Plan Formulary |
Fallon Senior Plan Plus Enhanced RX (HMO)
|
$166.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$5.00 | $15.00 | Q:30 /30Days | $3.00 |
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 |
Fallon Senior Plan Plus Enhanced RX (HMO)
|
$166.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$5.00 | $15.00 | Q:30 /30Days | $3.00 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$178.40 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$8.00 | $21.00 | Q:30 /30Days | $1.73 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$178.40 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$8.00 | $21.00 | Q:30 /30Days | $1.73 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$178.40 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$8.00 | $21.00 | Q:30 /30Days | $1.73 |
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:90 /365Days | $29.22 |
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:90 /365Days | $29.22 |
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 |
Medicare HMO Blue PlusRx (HMO)
|
$193.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Non-Preferred Generic |
$6.00 | $12.00 | Q:30 /30Days | $7.91 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$212.20 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$5.00 | $12.00 | Q:30 /30Days | $1.73 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$212.20 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$5.00 | $12.00 | Q:30 /30Days | $1.73 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$212.20 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$5.00 | $12.00 | Q:30 /30Days | $1.73 |
Browse Plan Formulary |