DEXMETHYLPHENIDATE ER 30 MG CP (NDC: 49884043001)
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 | 2 |
Tier 2 |
25% | 25% | Q:68 /34Days | $160.13 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | Q:68 /34Days | $160.25 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | Q:68 /34Days | $160.13 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | Q:68 /34Days | $160.13 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | Q:68 /34Days | $160.13 |
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 | $132.25 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | Q:30 /30Days | $184.75 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | Q:30 /30Days | $184.75 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | Q:30 /30Days | $187.06 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | Q:30 /30Days | $184.75 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | Q:30 /30Days | $184.75 |
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 |
HumanaChoice R5826-006 (Regional PPO)
|
$28.20 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | Q:30 /30Days | $186.59 |
Browse Plan Formulary |
Fidelis Secure Comfort (HMO SNP)
|
$30.40 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $183.90 |
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 | $132.25 |
Browse Plan Formulary |
Fidelis Secure Freedom (HMO SNP)
|
$31.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$4.00 | $8.00 | None | $183.90 |
Browse Plan Formulary |
BCN Advantage HMO ConnectedCare (HMO)
|
$41.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$15.00 | $37.50 | Q:68 /34Days | $160.13 |
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 | Q:30 /30Days | $176.20 |
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)
|
$58.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$12.00 | $30.00 | Q:30 /30Days | $184.75 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$12.00 | $30.00 | Q:30 /30Days | $184.75 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$12.00 | $30.00 | Q:30 /30Days | $184.75 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$12.00 | $30.00 | Q:30 /30Days | $184.75 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$12.00 | $30.00 | Q:30 /30Days | $187.06 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$12.00 | $30.00 | Q:30 /30Days | $184.75 |
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 |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$103.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:68 /34Days | $160.13 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$103.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:68 /34Days | $160.13 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$103.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:68 /34Days | $160.25 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$103.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:68 /34Days | $160.13 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$103.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:68 /34Days | $160.13 |
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 | Q:30 /30Days | $176.20 |
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 |
Alliance Medicare PPO (PPO)
|
$126.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$15.00 | $37.50 | Q:30 /30Days | $176.20 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$146.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:30 /30Days | $184.75 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$178.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$9.00 | $22.50 | Q:30 /30Days | $184.75 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$178.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$9.00 | $22.50 | Q:30 /30Days | $187.06 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$178.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$9.00 | $22.50 | Q:30 /30Days | $184.75 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$178.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$9.00 | $22.50 | Q:30 /30Days | $184.75 |
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 Select (PPO)
|
$178.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$9.00 | $22.50 | Q:30 /30Days | $184.75 |
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 | Q:30 /30Days | $176.20 |
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 | Q:30 /30Days | $176.20 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$244.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:68 /34Days | $160.13 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$244.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:68 /34Days | $160.13 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$244.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:68 /34Days | $160.13 |
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. | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:68 /34Days | $160.25 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$244.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:68 /34Days | $160.13 |
Browse Plan Formulary |