DIHYDROERGOTAMINE 4 MG/ML SPRAY (NDC: 68682035710)
2018 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
See your cost using a drug discount card: Compare prices at pharmacies near you |
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 HealthyValue (HMO)
|
$0.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$11.00 | $33.00 | Q:24 /90Days | $3,202.76 |
Browse Plan Formulary |
BCN Advantage HMO HealthyValue (HMO)
|
$0.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$11.00 | $33.00 | Q:24 /90Days | $3,174.67 |
Browse Plan Formulary |
BCN Advantage HMO HealthyValue (HMO)
|
$0.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$11.00 | $33.00 | Q:24 /90Days | $3,244.94 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | Q:24 /90Days | $3,223.84 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | Q:24 /90Days | $3,268.42 |
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 Basic (HMO-POS)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | Q:24 /90Days | $3,205.70 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | Q:24 /90Days | $3,164.62 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | Q:24 /90Days | $3,239.95 |
Browse Plan Formulary |
MeridianCare Essential (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | n/a | None | $976.13 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | n/a | Q:12 /30Days | $3,327.30 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | n/a | Q:12 /30Days | $3,276.40 |
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 |
$150* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | n/a | Q:12 /30Days | $3,329.82 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | n/a | Q:12 /30Days | $3,195.77 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | n/a | Q:12 /30Days | $3,010.90 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$9.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | n/a | Q:12 /30Days | $3,010.90 |
Browse Plan Formulary |
Aetna Medicare Value Plan (PPO)
|
$12.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:8 /28Days | $3,162.93 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$16.00 |
$100* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$11.00 | $33.00 | Q:24 /90Days | $3,174.67 |
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 |
BCN Advantage HMO HealthySaver (HMO)
|
$16.00 |
$100* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$11.00 | $33.00 | Q:24 /90Days | $3,244.94 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$16.00 |
$100* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$11.00 | $33.00 | Q:24 /90Days | $3,202.76 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$13.00 | n/a | Q:12 /30Days | $3,010.90 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$13.00 | n/a | Q:12 /30Days | $3,195.77 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$13.00 | n/a | Q:12 /30Days | $3,327.30 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$13.00 | n/a | Q:12 /30Days | $3,276.40 |
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 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$13.00 | n/a | Q:12 /30Days | $3,329.82 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$19.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | Q:24 /90Days | $3,268.38 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$19.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | Q:24 /90Days | $3,205.70 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$19.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | Q:24 /90Days | $3,164.62 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$19.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | Q:24 /90Days | $3,242.52 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$19.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | Q:24 /90Days | $3,223.84 |
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 |
MeridianCare Extra (HMO SNP)
|
$33.30 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | n/a | None | $976.13 |
Browse Plan Formulary |
BCN Advantage HMO MyChoice Wellness (HMO)
|
$35.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $30.00 | Q:24 /90Days | $3,244.94 |
Browse Plan Formulary |
BCN Advantage HMO MyChoice Wellness (HMO)
|
$35.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $30.00 | Q:24 /90Days | $3,202.76 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$37.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | Q:12 /30Days | $3,195.77 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$37.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | Q:12 /30Days | $3,327.30 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$37.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | Q:12 /30Days | $3,276.40 |
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)
|
$37.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | Q:12 /30Days | $3,329.82 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$37.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | Q:12 /30Days | $3,010.90 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$44.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | Q:24 /90Days | $3,242.52 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$44.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | Q:24 /90Days | $3,223.84 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$44.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | Q:24 /90Days | $3,268.38 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$44.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | Q:24 /90Days | $3,164.62 |
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 |
Medicare Plus Blue PPO Vitality (PPO)
|
$44.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | Q:24 /90Days | $3,205.70 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$46.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:8 /28Days | $3,162.93 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$90.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | n/a | Q:12 /30Days | $3,010.90 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | Q:24 /90Days | $3,205.70 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | Q:24 /90Days | $3,164.62 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | Q:24 /90Days | $3,239.95 |
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)
|
$113.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | Q:24 /90Days | $3,223.84 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | Q:24 /90Days | $3,268.42 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$129.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | n/a | Q:12 /30Days | $3,329.82 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$129.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | n/a | Q:12 /30Days | $3,010.90 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$129.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | n/a | Q:12 /30Days | $3,195.77 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$129.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | n/a | Q:12 /30Days | $3,327.30 |
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 Select (PPO)
|
$129.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | n/a | Q:12 /30Days | $3,276.40 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$129.50 |
$105* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $30.00 | Q:24 /90Days | $3,205.70 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$129.50 |
$105* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $30.00 | Q:24 /90Days | $3,164.62 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$129.50 |
$105* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $30.00 | Q:24 /90Days | $3,242.52 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$129.50 |
$105* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $30.00 | Q:24 /90Days | $3,223.84 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$129.50 |
$105* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $30.00 | Q:24 /90Days | $3,268.38 |
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 |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$200.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | Q:24 /90Days | $3,239.95 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$200.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | Q:24 /90Days | $3,223.84 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$200.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | Q:24 /90Days | $3,268.42 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$200.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | Q:24 /90Days | $3,205.70 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$200.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | Q:24 /90Days | $3,164.62 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$209.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$9.00 | $27.00 | Q:24 /90Days | $3,223.84 |
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)
|
$209.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$9.00 | $27.00 | Q:24 /90Days | $3,268.38 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$209.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$9.00 | $27.00 | Q:24 /90Days | $3,205.70 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$209.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$9.00 | $27.00 | Q:24 /90Days | $3,164.62 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$209.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$9.00 | $27.00 | Q:24 /90Days | $3,242.52 |
Browse Plan Formulary |