ACELLULAR PERTUSSIS VACCINE 50 UNT/ML / DIPHTHERIA TOXOID VACCINE 50 UNT/ML / TETANUS TOXOID VACCINE (NDC: 58160081011)
2017 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 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | n/a | None | $70.19 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | n/a | None | $71.42 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | n/a | None | $71.42 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | n/a | None | $71.42 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | n/a | None | $71.42 |
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 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | n/a | None | $68.56 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | n/a | None | $68.56 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | n/a | None | $71.45 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | n/a | None | $71.45 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | n/a | None | $71.45 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$18.00 |
$100 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | n/a | None | $71.42 |
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 HealthySaver (HMO)
|
$18.00 |
$100 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | n/a | None | $70.19 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$18.00 |
$100 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | n/a | None | $70.19 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | n/a | None | $71.45 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | n/a | None | $68.56 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | n/a | None | $68.56 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | n/a | None | $71.45 |
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)
|
$18.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | n/a | None | $71.45 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$21.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | n/a | None | $71.48 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$21.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | n/a | None | $70.19 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$21.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | n/a | None | $70.19 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$21.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | n/a | None | $71.48 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$21.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | n/a | None | $71.48 |
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 |
HumanaChoice R5826-006 (Regional PPO)
|
$25.50 |
$400 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
25% | 25% | None | $64.31 |
Browse Plan Formulary |
Humana Gold Plus H8908-002 (HMO)
|
$27.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $64.31 |
Browse Plan Formulary |
BCN Advantage HMO MyChoice Wellness (HMO)
|
$37.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | n/a | None | $70.19 |
Browse Plan Formulary |
BCN Advantage HMO MyChoice Wellness (HMO)
|
$37.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | n/a | None | $70.19 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$46.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | n/a | None | $70.19 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$46.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | n/a | None | $71.48 |
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 |
Medicare Plus Blue PPO Vitality (PPO)
|
$46.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | n/a | None | $71.48 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$46.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | n/a | None | $70.19 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$46.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | n/a | None | $71.48 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$47.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | n/a | None | $68.54 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$63.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | n/a | None | $71.39 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$63.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | n/a | None | $71.39 |
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)
|
$63.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | n/a | None | $71.39 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$63.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | n/a | None | $68.54 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$63.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | n/a | None | $68.54 |
Browse Plan Formulary |
HumanaChoice H5216-009 (PPO)
|
$69.00 |
$400 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $64.31 |
Browse Plan Formulary |
Humana Gold Choice H8145-006 (PFFS)
|
$97.00 |
$400 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $64.31 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$115.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | n/a | None | $71.42 |
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)
|
$115.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | n/a | None | $71.42 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$115.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | n/a | None | $70.19 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$115.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | n/a | None | $71.42 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$115.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | n/a | None | $71.42 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$122.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$38.00 | n/a | None | $68.54 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$131.00 |
$105 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | n/a | None | $70.19 |
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)
|
$131.00 |
$105 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | n/a | None | $71.48 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$131.00 |
$105 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | n/a | None | $70.19 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$131.00 |
$105 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | n/a | None | $71.48 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$131.00 |
$105 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | n/a | None | $71.48 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$154.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | n/a | None | $68.54 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$154.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | n/a | None | $68.54 |
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 |
PriorityMedicare Select (PPO)
|
$154.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | n/a | None | $71.39 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$154.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | n/a | None | $71.39 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$154.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | n/a | None | $71.39 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$202.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$35.00 | n/a | None | $71.42 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$202.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$35.00 | n/a | None | $71.42 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$202.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$35.00 | n/a | None | $71.42 |
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)
|
$202.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$35.00 | n/a | None | $71.42 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$202.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$35.00 | n/a | None | $70.19 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$211.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | n/a | None | $70.19 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$211.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | n/a | None | $71.48 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$211.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | n/a | None | $71.48 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$211.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | n/a | None | $70.19 |
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)
|
$211.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | n/a | None | $71.48 |
Browse Plan Formulary |