SELZENTRY 75 MG TABLET (NDC: 49702023508)
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 |
Advantra Silver (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $737.03 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (HMO)
|
$0.00 |
$275 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
27% | n/a | Q:60 /30Days | $737.03 |
Browse Plan Formulary |
BlueJourney Essential (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $746.05 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $692.48 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $692.48 |
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 Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $692.48 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $692.48 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $692.48 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $692.48 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $701.62 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $701.62 |
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 Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $701.62 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $701.62 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $701.62 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $701.62 |
Browse Plan Formulary |
Health Partners Medicare Value (HMO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | n/a | None | $707.49 |
Browse Plan Formulary |
Humana Gold Plus H6859-003 (HMO)
|
$0.00 |
$360 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | Q:120 /30Days | $708.97 |
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 |
Vibra Health Plan Essential Coverage (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $721.66 |
Browse Plan Formulary |
AARP MedicareComplete (HMO)
|
$16.00 |
$230 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | 28% | Q:90 /30Days | $739.30 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$16.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $718.91 |
Browse Plan Formulary |
UPMC for Life HMO Deductible with Rx (HMO)
|
$16.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | n/a | None | $718.46 |
Browse Plan Formulary |
UnitedHealthcare Assisted Living Plan (PPO SNP)
|
$19.00 |
$50 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
32% | 32% | Q:90 /30Days | $739.30 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$29.80 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | n/a | Q:90 /30Days | $739.30 |
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 |
Advantra Cares (HMO SNP)
|
$33.10 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | n/a | Q:60 /30Days | $737.89 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$34.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | n/a | Q:90 /30Days | $739.30 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H6859-008 (HMO SNP)
|
$34.90 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | Q:120 /30Days | $708.97 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete ONE (HMO SNP)
|
$35.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | n/a | Q:90 /30Days | $739.30 |
Browse Plan Formulary |
AARP MedicareComplete Choice Plan 1 (PPO)
|
$36.00 |
$230 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | 28% | Q:90 /30Days | $739.30 |
Browse Plan Formulary |
HumanaChoice R5826-002 (Regional PPO)
|
$36.40 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | Q:120 /30Days | $708.97 |
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 H5525-006 (PPO)
|
$37.00 |
$360 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | Q:120 /30Days | $708.97 |
Browse Plan Formulary |
AmeriHealth VIP Care (HMO SNP)
|
$39.40 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | n/a | Q:60 /30Days | $703.86 |
Browse Plan Formulary |
Gateway Health Medicare Assured Diamond (HMO SNP)
|
$39.40 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | n/a | Q:60 /30Days | $751.35 |
Browse Plan Formulary |
Gateway Health Medicare Assured Ruby (HMO SNP)
|
$39.40 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | Q:60 /30Days | $751.35 |
Browse Plan Formulary |
Geisinger Gold Secure Rx (HMO SNP)
|
$39.40 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | Q:60 /30Days | $701.62 |
Browse Plan Formulary |
Health Partners Medicare Prime (HMO)
|
$39.40 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | n/a | None | $707.49 |
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 Partners Medicare Special (HMO SNP)
|
$39.40 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | None | $707.49 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (HMO)
|
$49.00 |
$100 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
31% | n/a | Q:60 /30Days | $737.03 |
Browse Plan Formulary |
Vibra Health Plan Enhanced Coverage (PPO)
|
$49.50 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $721.66 |
Browse Plan Formulary |
BlueJourney Value (HMO)
|
$50.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $746.05 |
Browse Plan Formulary |
BlueJourney Classic (PPO)
|
$55.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $746.05 |
Browse Plan Formulary |
Advantra Silver Plus (HMO)
|
$61.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $737.03 |
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 |
AARP MedicareComplete Choice Plan 2 (PPO)
|
$66.00 |
$210 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | 28% | Q:90 /30Days | $739.30 |
Browse Plan Formulary |
Freedom Blue PPO ValueRx (PPO)
|
$75.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $718.91 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$75.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $701.62 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$75.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $701.62 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$75.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $701.62 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$75.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $701.62 |
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 Advantage Rx (PPO)
|
$75.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $701.62 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$75.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $701.62 |
Browse Plan Formulary |
Advantra Silver Plus (PPO)
|
$84.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $737.03 |
Browse Plan Formulary |
UPMC for Life HMO Rx (HMO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | n/a | None | $718.46 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$117.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $692.48 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$117.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $692.48 |
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 Classic Advantage Rx (HMO)
|
$117.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $692.48 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$117.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $692.48 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$117.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $692.48 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$117.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $692.48 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$119.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $737.03 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$125.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $737.03 |
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 |
BlueJourney Premier (HMO)
|
$150.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $746.05 |
Browse Plan Formulary |
Aetna Medicare Gold Plan (PPO)
|
$159.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $737.03 |
Browse Plan Formulary |
BlueJourney Prime (PPO)
|
$175.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $746.05 |
Browse Plan Formulary |
Freedom Blue PPO Standard (PPO)
|
$190.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $718.91 |
Browse Plan Formulary |
Humana Gold Choice H8145-053 (PFFS)
|
$193.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $708.97 |
Browse Plan Formulary |
Freedom Blue PPO Deluxe (PPO)
|
$293.50 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $718.91 |
Browse Plan Formulary |