ZIRGAN 1.5mg/g 1 TUBE, WITH APPLICATOR per CARTON / 5 g in 1 TUBE, WITH APPLICATOR (1 TUBE, WITH APPLICATOR i ) (NDC: 24208053535)
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 | 3 |
Tier 3 |
25% | 25% | None | $282.43 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $282.21 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $282.37 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $282.73 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $281.76 |
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 Value (HMO-POS)
|
$7.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $284.59 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $284.59 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $286.93 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $285.86 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $284.36 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $284.45 |
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 | 3 |
Tier 3 |
25% | 25% | None | $282.67 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $281.76 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $282.72 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $282.84 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $282.26 |
Browse Plan Formulary |
HumanaChoice R5826-006 (Regional PPO)
|
$28.20 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | Q:5 /30Days | $281.75 |
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)
|
$30.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $284.45 |
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 | $284.59 |
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 | $286.93 |
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 | $285.86 |
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 | $284.36 |
Browse Plan Formulary |
Fidelis Secure Comfort (HMO SNP)
|
$30.40 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $284.38 |
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 |
Fidelis Secure Freedom (HMO SNP)
|
$31.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$35.00 | $70.00 | None | $284.38 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $282.72 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $282.84 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $282.26 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $282.67 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $281.76 |
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 H5216-009 (PPO)
|
$67.00 |
$320 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:5 /30Days | $282.97 |
Browse Plan Formulary |
Humana Gold Choice H8145-005 (PFFS)
|
$83.00 |
$320 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:5 /30Days | $282.13 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$91.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | None | $281.76 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$91.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | None | $282.73 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$91.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | None | $282.43 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$91.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | None | $282.21 |
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)
|
$91.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | None | $282.37 |
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 | $284.59 |
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 | $284.45 |
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 | $284.59 |
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 | $284.36 |
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 | $285.86 |
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 | $286.93 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$110.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $282.72 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$110.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $281.76 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$110.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $282.84 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$110.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $282.26 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$110.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $282.67 |
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. | 3 |
Preferred Brand |
$40.00 | $100.00 | None | $281.76 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$182.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | None | $282.67 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$182.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | None | $282.72 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$182.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | None | $282.84 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$182.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | None | $282.26 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$196.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $87.50 | None | $281.76 |
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)
|
$196.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $87.50 | None | $282.73 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$196.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $87.50 | None | $282.37 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$196.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $87.50 | None | $282.21 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$196.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $87.50 | None | $282.43 |
Browse Plan Formulary |