ANDRODERM 4 MG/24HR PATCH (30 EA ) (NDC: 52544007730)
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 |
Aetna Better Health Premier Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | P Q:30 /30Days | $412.25 |
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% | P Q:34 /34Days | $409.62 |
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% | P Q:34 /34Days | $409.15 |
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% | P Q:34 /34Days | $408.18 |
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% | P Q:34 /34Days | $408.21 |
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 Basic (HMO-POS)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | P Q:34 /34Days | $408.86 |
Browse Plan Formulary |
Fidelis Secure Respect (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$45.00 | $90.00 | P | $411.18 |
Browse Plan Formulary |
HAP Midwest MI Health Link (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | n/a | P Q:30 /30Days | $419.62 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | P Q:30 /30Days | $410.67 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | P Q:30 /30Days | $411.95 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | P Q:30 /30Days | $410.12 |
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 |
3 |
Tier 3 |
25% | 25% | P Q:30 /30Days | $412.77 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | P Q:30 /30Days | $413.45 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | P Q:30 /30Days | $412.65 |
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% | P Q:90 /90Days | $409.66 |
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% | P Q:90 /90Days | $408.99 |
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% | P Q:90 /90Days | $408.68 |
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% | P Q:90 /90Days | $408.21 |
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% | P Q:90 /90Days | $408.54 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$28.60 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:30 /30Days | $410.68 |
Browse Plan Formulary |
HAP Midwest Health Plan (HMO SNP)
|
$31.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Brand |
$0.00 | n/a | P Q:30 /30Days | $418.87 |
Browse Plan Formulary |
McLaren Advantage Sapphire (HMO)
|
$36.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$35.00 | $78.75 | P Q:30 /30Days | $419.04 |
Browse Plan Formulary |
McLaren Advantage Sapphire (HMO)
|
$36.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$35.00 | $78.75 | P Q:30 /30Days | $418.60 |
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 |
3 |
Preferred Brand |
$45.00 | $112.50 | P Q:34 /34Days | $408.29 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$58.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | P Q:30 /30Days | $413.45 |
Browse Plan Formulary |
Fidelis Secure Premier (HMO)
|
$64.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Preferred Brand |
$40.00 | $80.00 | P | $411.18 |
Browse Plan Formulary |
McLaren Advantage Diamond (HMO)
|
$72.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$35.00 | $78.75 | P Q:30 /30Days | $419.04 |
Browse Plan Formulary |
McLaren Advantage Diamond (HMO)
|
$72.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$35.00 | $78.75 | P Q:30 /30Days | $418.60 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | P Q:30 /30Days | $411.95 |
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 |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | P Q:30 /30Days | $410.12 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | P Q:30 /30Days | $412.77 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | P Q:30 /30Days | $413.45 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | P Q:30 /30Days | $412.65 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$100.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | P Q:90 /90Days | $408.54 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$100.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | P Q:90 /90Days | $409.66 |
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)
|
$100.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | P Q:90 /90Days | $408.99 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$100.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | P Q:90 /90Days | $408.68 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$100.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | P Q:90 /90Days | $408.21 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$138.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | P Q:34 /34Days | $408.18 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$138.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | P Q:34 /34Days | $408.21 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$138.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | P Q:34 /34Days | $408.86 |
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 |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$138.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | P Q:34 /34Days | $409.62 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$138.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | P Q:34 /34Days | $409.15 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$146.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $100.00 | P Q:30 /30Days | $413.45 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$159.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | P Q:90 /90Days | $408.68 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$159.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | P Q:90 /90Days | $408.21 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$159.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | P Q:90 /90Days | $408.54 |
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)
|
$159.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | P Q:90 /90Days | $409.66 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$159.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | P Q:90 /90Days | $408.99 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$178.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $100.00 | P Q:30 /30Days | $412.65 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$178.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $100.00 | P Q:30 /30Days | $411.95 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$178.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $100.00 | P Q:30 /30Days | $410.12 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$178.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $100.00 | P Q:30 /30Days | $412.77 |
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 |
3 |
Preferred Brand |
$40.00 | $100.00 | P Q:30 /30Days | $413.45 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$262.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | $87.50 | P Q:34 /34Days | $408.86 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$262.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | $87.50 | P Q:34 /34Days | $409.62 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$262.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | $87.50 | P Q:34 /34Days | $409.15 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$262.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | $87.50 | P Q:34 /34Days | $408.21 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$262.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | $87.50 | P Q:34 /34Days | $408.18 |
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)
|
$283.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | P Q:90 /90Days | $408.68 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$283.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | P Q:90 /90Days | $408.21 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$283.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | P Q:90 /90Days | $408.54 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$283.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | P Q:90 /90Days | $409.66 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$283.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | P Q:90 /90Days | $408.99 |
Browse Plan Formulary |