ANDROGEL 1.62% (1.25G) GEL PCKT (1.5 GM ) (NDC: 00051846231)
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 |
Advantra Silver (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | P | $485.93 |
Browse Plan Formulary |
Advantra Silver (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | P | $485.82 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$39.00 | $117.00 | None | $477.97 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$39.00 | $117.00 | None | $475.11 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$39.00 | $117.00 | None | $490.86 |
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 |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$39.00 | $117.00 | None | $476.58 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$39.00 | $117.00 | None | $471.16 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$39.00 | $117.00 | None | $471.16 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$39.00 | $117.00 | None | $477.97 |
Browse Plan Formulary |
Humana Gold Plus H6859-003 (HMO)
|
$0.00 |
$320* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$45.00 | $125.00 | Q:38 /30Days | $477.95 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$27.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | P | $479.48 |
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 |
Geisinger Gold Preferred Essential Rx (PPO)
|
$31.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$39.00 | $117.00 | None | $469.40 |
Browse Plan Formulary |
Advantra Cares (HMO SNP)
|
$33.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | P | $486.11 |
Browse Plan Formulary |
AmeriHealth VIP Care (HMO SNP)
|
$33.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | None | $483.30 |
Browse Plan Formulary |
Geisinger Gold Secure Rx (HMO SNP)
|
$33.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $473.15 |
Browse Plan Formulary |
HumanaChoice H5525-006 (PPO)
|
$34.00 |
$320* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$45.00 | $125.00 | Q:38 /30Days | $477.95 |
Browse Plan Formulary |
AARP MedicareComplete Choice Plan 1 (PPO)
|
$39.00 |
$230 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | P | $480.46 |
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 R5826-002 (Regional PPO)
|
$39.90 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$45.00 | $125.00 | Q:38 /30Days | $479.13 |
Browse Plan Formulary |
Advantra Silver Plus (HMO)
|
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | P | $485.82 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (HMO)
|
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | P | $486.29 |
Browse Plan Formulary |
AARP MedicareComplete Choice Plan 2 (PPO)
|
$59.00 |
$210 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | P | $480.46 |
Browse Plan Formulary |
Advantra Silver Plus (PPO)
|
$67.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | P | $485.82 |
Browse Plan Formulary |
Freedom Blue PPO HD Rx (PPO)
|
$70.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | P | $493.76 |
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 |
SeniorBlue - Option 2 (PPO)
|
$72.40 |
$0 |
to be determined |
4 |
Tier 4 |
$90.00 | $270.00 | P Q:150 /30Days | $486.63 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$75.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$39.00 | $117.00 | None | $471.16 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$75.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$39.00 | $117.00 | None | $477.97 |
Browse Plan Formulary |
Freedom Blue PPO ValueRx (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | P | $493.76 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$116.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $112.50 | P | $485.82 |
Browse Plan Formulary |
SeniorBlue - Option 2 (HMO)
|
$117.50 |
$0 |
to be determined |
4 |
Tier 4 |
$89.00 | $267.00 | P Q:150 /30Days | $486.58 |
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 |
Geisinger Gold Classic Advantage Rx (HMO)
|
$119.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$39.00 | $117.00 | None | $471.16 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$119.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$39.00 | $117.00 | None | $477.97 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$119.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$39.00 | $117.00 | None | $475.11 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$119.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$39.00 | $117.00 | None | $490.86 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$119.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$39.00 | $117.00 | None | $476.58 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$124.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | P | $486.29 |
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 |
Aetna Medicare Select Plus Plan (PPO)
|
$139.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $112.50 | P | $486.39 |
Browse Plan Formulary |
SeniorBlue - Option 1 (HMO)
|
$167.50 |
$0 |
to be determined |
4 |
Tier 4 |
$89.00 | $267.00 | P Q:150 /30Days | $486.58 |
Browse Plan Formulary |
SeniorBlue - Option 1 (PPO)
|
$191.90 |
$0 |
to be determined |
4 |
Tier 4 |
$89.00 | $267.00 | P Q:150 /30Days | $486.63 |
Browse Plan Formulary |
Humana Gold Choice H8145-053 (PFFS)
|
$195.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:38 /30Days | $479.44 |
Browse Plan Formulary |
Freedom Blue PPO Standard (PPO)
|
$246.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | P | $493.76 |
Browse Plan Formulary |
Freedom Blue PPO Deluxe (PPO)
|
$296.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $112.50 | P | $493.76 |
Browse Plan Formulary |