ADVICOR ER 20-750MG TABLET (90 CT) (90 BOTPL) (NDC: 00074307290)
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 |
Anthem Select Advantage (HMO)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:60 /30Days | $216.98 |
Browse Plan Formulary |
Anthem Select Advantage (HMO)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:60 /30Days | $216.98 |
Browse Plan Formulary |
Blue Cross Senior Secure Plan I (HMO)
|
$0.00 |
$50 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:60 /30Days | $212.32 |
Browse Plan Formulary |
Blue Cross Senior Secure Plan I (HMO)
|
$0.00 |
$50 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:60 /30Days | $212.32 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:60 /30Days | $213.24 |
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 |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:60 /30Days | $213.24 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | Q:60 /30Days | $213.24 |
Browse Plan Formulary |
Citizens Choice Health Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$30.00 | $60.00 | None | $214.10 |
Browse Plan Formulary |
Citizens Choice Health Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$30.00 | $60.00 | None | $214.10 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$89.00 | $222.50 | None | $217.18 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$89.00 | $222.50 | None | $217.18 |
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 |
Easy Choice Freedom Plan (HMO SNP)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None | $219.34 |
Browse Plan Formulary |
Golden State Medicare Health Plan, Golden (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$95.00 | $190.00 | Q:60 /30Days | $216.28 |
Browse Plan Formulary |
Golden State Medicare Health Plan, Golden (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$95.00 | $190.00 | Q:60 /30Days | $209.43 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None | $213.49 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None | $211.89 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None | $213.49 |
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 |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | None | $211.89 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $245.00 | None | $213.42 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $245.00 | None | $212.17 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $245.00 | None | $213.42 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $245.00 | None | $212.17 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $211.89 |
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 |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $211.89 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $212.33 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $212.30 |
Browse Plan Formulary |
Heart First (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:31 /31Days | $212.32 |
Browse Plan Formulary |
Heart First (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:31 /31Days | $212.32 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$95.00 | $190.00 | None | $231.00 |
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 |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$95.00 | $190.00 | None | $231.00 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $231.00 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $231.00 |
Browse Plan Formulary |
Platinum Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$30.00 | $60.00 | None | $212.88 |
Browse Plan Formulary |
Platinum Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$30.00 | $60.00 | None | $212.88 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:31 /31Days | $212.32 |
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 |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:31 /31Days | $212.32 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:31 /31Days | $217.05 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:31 /31Days | $217.05 |
Browse Plan Formulary |
SCAN Connections (HMO SNP)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:31 /31Days | $211.07 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:31 /31Days | $217.05 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:31 /31Days | $211.98 |
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 |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:31 /31Days | $211.98 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $231.00 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$15.30 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $231.00 |
Browse Plan Formulary |
Easy Choice Freedom Plan (HMO SNP)
|
$23.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None | $219.34 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$23.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None | $219.34 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$23.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None | $219.34 |
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 |
CalPlus Plan (HMO)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | None | $213.66 |
Browse Plan Formulary |
CalPlus Plan (HMO)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | None | $213.66 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $212.33 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $212.30 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $212.41 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $212.41 |
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 |
SCAN Connections (HMO SNP)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:31 /31Days | $211.07 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:31 /31Days | $217.05 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:31 /31Days | $211.07 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:31 /31Days | $211.07 |
Browse Plan Formulary |
VillageHealth (HMO SNP)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:31 /31Days | $212.32 |
Browse Plan Formulary |
VillageHealth (HMO SNP)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:31 /31Days | $212.32 |
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 |
Health Net Seniority Plus Complete (HMO)
|
$66.30 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $212.44 |
Browse Plan Formulary |
Health Net Seniority Plus Complete (HMO)
|
$176.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $212.44 |
Browse Plan Formulary |