EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H (30 PATCHES CRTN) (NDC: 49502090030)
2016 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 |
Brand Drugs |
0% | 0% | S Q:30 /30Days | $1,538.65 |
Browse Plan Formulary |
AmeriHealth Caritas VIP Care PLUS (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | None | $1,526.49 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$360 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,539.48 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$360 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,536.54 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$360 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,521.37 |
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 |
$360 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,535.63 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$360 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,526.92 |
Browse Plan Formulary |
Fidelis SecureLife (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | None | $1,614.51 |
Browse Plan Formulary |
HAP Midwest MI Health Link (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | n/a | None | $1,564.97 |
Browse Plan Formulary |
Harbor Medicare (HMO)
|
$0.00 |
$240 |
to be determined |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $1,524.97 |
Browse Plan Formulary |
HealthPlus MedicarePlus Option 0 (HMO)
|
$0.00 |
$360 |
to be determined |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:30 /30Days | $1,521.92 |
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 |
$0 |
to be determined |
3 |
Tier 3 |
$47.00 | $94.00 | None | $1,557.45 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | P Q:30 /30Days | $1,535.39 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$360 |
to be determined |
3 |
Tier 3 |
25% | 25% | S | $1,562.51 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$360 |
to be determined |
3 |
Tier 3 |
25% | 25% | S | $1,492.60 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$360 |
to be determined |
3 |
Tier 3 |
25% | 25% | S | $1,560.28 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$360 |
to be determined |
3 |
Tier 3 |
25% | 25% | S | $1,528.78 |
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 Key (HMO-POS)
|
$0.00 |
$360 |
to be determined |
3 |
Tier 3 |
25% | 25% | S | $1,509.76 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$360 |
to be determined |
3 |
Tier 3 |
25% | 25% | S | $1,509.76 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$360 |
to be determined |
3 |
Tier 3 |
25% | 25% | S | $1,562.51 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$360 |
to be determined |
3 |
Tier 3 |
25% | 25% | S | $1,492.60 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$360 |
to be determined |
3 |
Tier 3 |
25% | 25% | S | $1,560.28 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$360 |
to be determined |
3 |
Tier 3 |
25% | 25% | S | $1,528.78 |
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)
|
$20.50 |
$360 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,534.81 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$20.50 |
$360 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,536.54 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$20.50 |
$360 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,521.37 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$20.50 |
$360 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,544.71 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$20.50 |
$360 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,526.92 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$33.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,535.49 |
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 |
HAP Midwest Health Plan (HMO SNP)
|
$33.50 |
$360 |
to be determined |
2 |
Brand |
25% | n/a | None | $1,562.89 |
Browse Plan Formulary |
Meridian Advantage Plan of Michigan (HMO SNP)
|
$33.50 |
$360 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | None | $1,557.45 |
Browse Plan Formulary |
BCN Advantage HMO ConnectedCare (HMO)
|
$47.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None | $1,527.49 |
Browse Plan Formulary |
Harbor Medicare Select (HMO)
|
$47.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $1,524.97 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$59.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
23% | 23% | None | $1,562.04 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$66.00 |
$75 |
to be determined |
3 |
Tier 3 |
$45.00 | $112.50 | S | $1,560.28 |
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 |
HAP Senior Plus - Henry Ford (HMO)
|
$79.00 |
$200 |
to be determined |
4 |
Non-Preferred Brand |
28% | 28% | None | $1,563.72 |
Browse Plan Formulary |
McLaren Advantage Sapphire (HMO)
|
$81.00 |
$150 |
to be determined |
4 |
Specialty Tier |
29% | n/a | None | $1,563.95 |
Browse Plan Formulary |
McLaren Advantage Sapphire (HMO)
|
$81.00 |
$150 |
to be determined |
4 |
Specialty Tier |
29% | n/a | None | $1,565.02 |
Browse Plan Formulary |
Humana Gold Plus H8908-001 (HMO)
|
$89.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | Q:30 /30Days | $1,515.18 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75 |
to be determined |
3 |
Tier 3 |
$45.00 | $112.50 | S | $1,509.76 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75 |
to be determined |
3 |
Tier 3 |
$45.00 | $112.50 | S | $1,562.51 |
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 |
$75 |
to be determined |
3 |
Tier 3 |
$45.00 | $112.50 | S | $1,492.60 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75 |
to be determined |
3 |
Tier 3 |
$45.00 | $112.50 | S | $1,560.28 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75 |
to be determined |
3 |
Tier 3 |
$45.00 | $112.50 | S | $1,528.78 |
Browse Plan Formulary |
HealthPlus MedicarePlus Option 1 (HMO)
|
$98.00 |
$100 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:30 /30Days | $1,521.92 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$106.00 |
$360 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,544.71 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$106.00 |
$360 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,526.92 |
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)
|
$106.00 |
$360 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,534.81 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$106.00 |
$360 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,536.54 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$106.00 |
$360 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,521.37 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$109.00 |
$100 |
to be determined |
4 |
Non-Preferred Brand |
28% | 28% | None | $1,562.04 |
Browse Plan Formulary |
McLaren Advantage Diamond (HMO)
|
$117.00 |
$150 |
to be determined |
4 |
Specialty Tier |
29% | n/a | None | $1,563.95 |
Browse Plan Formulary |
McLaren Advantage Diamond (HMO)
|
$117.00 |
$150 |
to be determined |
4 |
Specialty Tier |
29% | n/a | None | $1,565.02 |
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)
|
$121.00 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | Q:30 /30Days | $1,514.55 |
Browse Plan Formulary |
Alliance Medicare PPO (PPO)
|
$126.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
33% | 33% | None | $1,561.52 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$146.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $100.00 | S | $1,560.28 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$154.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None | $1,521.37 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$154.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None | $1,535.63 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$154.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None | $1,526.92 |
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)
|
$154.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None | $1,539.48 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$154.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$80.00 | $200.00 | None | $1,536.54 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$169.00 |
$100 |
to be determined |
4 |
Non-Preferred Brand |
$98.00 | $245.00 | None | $1,521.37 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$169.00 |
$100 |
to be determined |
4 |
Non-Preferred Brand |
$98.00 | $245.00 | None | $1,544.71 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$169.00 |
$100 |
to be determined |
4 |
Non-Preferred Brand |
$98.00 | $245.00 | None | $1,526.92 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$169.00 |
$100 |
to be determined |
4 |
Non-Preferred Brand |
$98.00 | $245.00 | None | $1,534.81 |
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)
|
$169.00 |
$100 |
to be determined |
4 |
Non-Preferred Brand |
$98.00 | $245.00 | None | $1,536.54 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$193.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $100.00 | S | $1,528.78 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$193.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $100.00 | S | $1,509.76 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$193.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $100.00 | S | $1,562.51 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$193.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $100.00 | S | $1,492.60 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$193.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $100.00 | S | $1,560.28 |
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)
|
$210.00 |
$150 |
to be determined |
4 |
Non-Preferred Brand |
29% | 29% | None | $1,561.52 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$220.00 |
$50 |
to be determined |
4 |
Non-Preferred Brand |
31% | 31% | None | $1,562.04 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$283.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$75.00 | $187.50 | None | $1,526.92 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$283.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$75.00 | $187.50 | None | $1,535.63 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$283.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$75.00 | $187.50 | None | $1,539.48 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$283.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$75.00 | $187.50 | None | $1,536.54 |
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 |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$283.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$75.00 | $187.50 | None | $1,521.37 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$294.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | None | $1,536.54 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$294.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | None | $1,521.37 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$294.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | None | $1,544.71 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$294.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | None | $1,526.92 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$294.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$97.00 | $242.50 | None | $1,534.81 |
Browse Plan Formulary |