ACETAMINOPHEN AND CODEINE PHOSPHATE TABLET USP 300MG-15MG (100 CT) (100 BOT) (NDC: 00093005001)
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:240 /30Days | $29.30 |
Browse Plan Formulary |
Harbor Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | n/a | Q:390 /30Days | $28.04 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | Q:360 /30Days | $21.34 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | Q:360 /30Days | $22.60 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | Q:360 /30Days | $22.30 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | Q:360 /30Days | $21.48 |
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 |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | Q:360 /30Days | $21.90 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$5.10 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | n/a | Q:400 /30Days | $28.20 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | Q:360 /30Days | $21.90 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | Q:360 /30Days | $21.34 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | Q:360 /30Days | $22.60 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | Q:360 /30Days | $22.30 |
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 |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | Q:360 /30Days | $21.48 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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% | Q:390 /30Days | $16.67 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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 | $21.43 |
Browse Plan Formulary |
Erickson Advantage Guardian (HMO-POS SNP)
|
$35.80 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | Q:390 /30Days | $25.28 |
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 |
Erickson Advantage Freedom (HMO-POS)
|
$46.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $0.00 | Q:390 /30Days | $25.28 |
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 | Q:240 /30Days | $29.30 |
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 | Q:1080 /90Days | $8.56 |
Browse Plan Formulary |
Harbor Medicare Select (HMO)
|
$60.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | n/a | Q:390 /30Days | $28.04 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$66.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | n/a | Q:360 /30Days | $23.35 |
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 | Q:390 /30Days | $16.67 |
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 |
2 |
Generic |
$5.00 | $15.00 | Q:180 /30Days | $21.96 |
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 | Q:240 /30Days | $29.30 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | Q:360 /30Days | $23.61 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | Q:360 /30Days | $23.35 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | Q:360 /30Days | $22.72 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | Q:360 /30Days | $22.51 |
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* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | Q:360 /30Days | $23.16 |
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 | Q:240 /30Days | $29.30 |
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 | Q:390 /30Days | $16.67 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:240 /30Days | $29.30 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$145.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | n/a | Q:360 /30Days | $23.35 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
Browse Plan Formulary |
Erickson Advantage Champion (HMO-POS SNP)
|
$176.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $0.00 | Q:390 /30Days | $25.28 |
Browse Plan Formulary |
Erickson Advantage Signature with Drugs (HMO-POS)
|
$176.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $0.00 | Q:390 /30Days | $25.28 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$201.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | n/a | Q:360 /30Days | $22.51 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$201.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | n/a | Q:360 /30Days | $23.16 |
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 |
2 |
Generic |
$7.00 | n/a | Q:360 /30Days | $23.61 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$201.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | n/a | Q:360 /30Days | $23.35 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$201.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | n/a | Q:360 /30Days | $22.72 |
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 | Q:240 /30Days | $29.30 |
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 | Q:240 /30Days | $29.30 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
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 | Q:1080 /90Days | $8.56 |
Browse Plan Formulary |