SERTRALINE 20 MG/ML ORAL CONC (60 ML ) (NDC: 16714060102)
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 | 2 |
Generic |
$18.00 | n/a | None | $48.65 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$18.00 | n/a | None | $48.65 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$18.00 | n/a | None | $48.65 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$18.00 | n/a | None | $48.65 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$18.00 | n/a | None | $48.65 |
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 (HMO)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$11.00 | n/a | None | $52.22 |
Browse Plan Formulary |
Harbor Medicare (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$10.00 | n/a | None | $52.47 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $49.02 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $48.34 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $49.84 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $49.68 |
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 | 1 |
Tier 1 |
25% | n/a | None | $55.18 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$5.10 |
$400 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
46% | n/a | None | $51.12 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $49.68 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $55.18 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $49.02 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $48.34 |
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 |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $49.84 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$25.00 |
$100* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$20.00 | n/a | None | $48.65 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$25.00 |
$100* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$20.00 | n/a | None | $48.65 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$25.00 |
$100* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$20.00 | n/a | None | $48.65 |
Browse Plan Formulary |
HumanaChoice R5826-006 (Regional PPO)
|
$25.50 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | 25% | None | $46.07 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$25.50 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | None | $48.65 |
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)
|
$25.50 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | None | $48.65 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$25.50 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | None | $48.65 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$25.50 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | None | $48.65 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$25.50 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | None | $48.65 |
Browse Plan Formulary |
HAP Midwest Health Plan (HMO SNP)
|
$34.20 |
$370 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
25% | n/a | None | $46.45 |
Browse Plan Formulary |
Erickson Advantage Guardian (HMO-POS SNP)
|
$35.80 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$70.00 | $200.00 | None | $33.72 |
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 |
Erickson Advantage Freedom (HMO-POS)
|
$46.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$85.00 | $245.00 | None | $33.72 |
Browse Plan Formulary |
HAP Senior Plus Option 1 (HMO-POS)
|
$48.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$11.00 | n/a | None | $52.22 |
Browse Plan Formulary |
BCN Advantage HMO ConnectedCare (HMO)
|
$58.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | n/a | None | $48.65 |
Browse Plan Formulary |
Harbor Medicare Select (HMO)
|
$60.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$4.00 | n/a | None | $52.47 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$66.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$2.00 | n/a | None | $51.70 |
Browse Plan Formulary |
Humana Gold Plus H8908-001 (HMO)
|
$73.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $46.07 |
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 Premier Plan (PPO)
|
$75.00 |
$245 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $30.82 |
Browse Plan Formulary |
HAP Senior Plus Henry Ford Tiered Access (HMO)
|
$77.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | n/a | None | $52.22 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$2.00 | n/a | None | $50.66 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$2.00 | n/a | None | $55.54 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$2.00 | n/a | None | $51.70 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$2.00 | n/a | None | $48.62 |
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 |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$2.00 | n/a | None | $51.38 |
Browse Plan Formulary |
HAP Senior Plus Option 2 (HMO-POS)
|
$97.00 |
$100* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | n/a | None | $52.22 |
Browse Plan Formulary |
HumanaChoice H5216-011 (PPO)
|
$108.00 |
$400 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $46.07 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$111.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | None | $48.65 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$111.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | None | $48.65 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$111.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | None | $48.65 |
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)
|
$111.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | None | $48.65 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$111.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | None | $48.65 |
Browse Plan Formulary |
HAP Senior Plus Option 1 (PPO)
|
$124.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | n/a | None | $52.22 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$145.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$1.00 | n/a | None | $51.70 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$166.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | None | $48.65 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$166.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | None | $48.65 |
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)
|
$166.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | None | $48.65 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$166.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | None | $48.65 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$166.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | None | $48.65 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$174.00 |
$105* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | n/a | None | $48.65 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$174.00 |
$105* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | n/a | None | $48.65 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$174.00 |
$105* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | n/a | None | $48.65 |
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)
|
$174.00 |
$105* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | n/a | None | $48.65 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$174.00 |
$105* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | n/a | None | $48.65 |
Browse Plan Formulary |
Erickson Advantage Champion (HMO-POS SNP)
|
$176.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$85.00 | $245.00 | None | $33.72 |
Browse Plan Formulary |
Erickson Advantage Signature with Drugs (HMO-POS)
|
$176.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$85.00 | $245.00 | None | $33.72 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$201.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$1.00 | n/a | None | $48.62 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$201.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$1.00 | n/a | None | $51.38 |
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)
|
$201.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$1.00 | n/a | None | $50.66 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$201.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$1.00 | n/a | None | $55.54 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$201.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$1.00 | n/a | None | $51.70 |
Browse Plan Formulary |
HAP Senior Plus Option 2 (PPO)
|
$208.00 |
$150* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$10.00 | n/a | None | $52.22 |
Browse Plan Formulary |
HAP Senior Plus Option 3 (HMO-POS)
|
$218.00 |
$50* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$10.00 | n/a | None | $52.22 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$303.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | None | $48.65 |
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)
|
$303.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | None | $48.65 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$303.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | None | $48.65 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$303.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | None | $48.65 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$303.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | None | $48.65 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$314.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$14.00 | n/a | None | $48.65 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$314.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$14.00 | n/a | None | $48.65 |
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)
|
$314.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$14.00 | n/a | None | $48.65 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$314.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$14.00 | n/a | None | $48.65 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$314.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$14.00 | n/a | None | $48.65 |
Browse Plan Formulary |