DOFETILIDE 125 MCG CAPSULE [Tikosyn] (60 EA ) (NDC: 51862012560)
2018 Medicare Prescription Drug Plan (MAPD) Information
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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 |
AARP MedicareComplete Choice Plan 2 (Regional PPO)
|
$0.00 |
$395 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $340.71 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (HMO-POS)
|
$0.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $128.54 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $133.32 |
Browse Plan Formulary |
Allwell Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$35.00 | n/a | None | $349.96 |
Browse Plan Formulary |
Allwell Medicare Premier (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$60.00 | n/a | None | $349.96 |
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 |
AvMed Medicare Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $187.50 | None | $385.69 |
Browse Plan Formulary |
BlueMedicare Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | n/a | None | $358.18 |
Browse Plan Formulary |
BlueMedicare Premier (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | n/a | None | $358.18 |
Browse Plan Formulary |
CareFree PLUS (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:240 /30Days | $292.07 |
Browse Plan Formulary |
CareOne PLUS (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$35.00 | $95.00 | Q:240 /30Days | $292.07 |
Browse Plan Formulary |
Coventry Medicare Summit Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $146.43 |
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 |
Coventry Medicare Vista Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $146.43 |
Browse Plan Formulary |
Freedom Medicare Plan Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Drug |
$85.00 | n/a | None | $403.37 |
Browse Plan Formulary |
Freedom VIP Care (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Drug |
$75.00 | n/a | None | $402.84 |
Browse Plan Formulary |
Freedom VIP Savings (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Drug |
$80.00 | n/a | None | $402.52 |
Browse Plan Formulary |
Freedom VIP Savings COPD (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Drug |
$80.00 | n/a | None | $402.52 |
Browse Plan Formulary |
HealthSun SunPlus Advantage Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | n/a | None | $435.84 |
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 |
Humana Gold Plus H1036-054C (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$45.00 | $125.00 | Q:240 /30Days | $292.07 |
Browse Plan Formulary |
Humana Gold Plus H1036-237 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:240 /30Days | $292.07 |
Browse Plan Formulary |
Humana Gold Plus H1036-237 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:240 /30Days | $292.07 |
Browse Plan Formulary |
HumanaChoice Florida H5216-068 (PPO)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:240 /30Days | $292.07 |
Browse Plan Formulary |
HumanaChoice R5826-074 (Regional PPO)
|
$0.00 |
$405 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:240 /30Days | $292.07 |
Browse Plan Formulary |
Leon Medical Centers Health Plans - Leon Cares (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic |
$0.00 | n/a | None | $248.85 |
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 |
Medica HealthCare Plans MedicareMax (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$65.00 | $185.00 | None | $366.92 |
Browse Plan Formulary |
Optimum Gold Rewards Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Drug |
$85.00 | n/a | None | $406.92 |
Browse Plan Formulary |
Optimum Platinum Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Drug |
$69.00 | n/a | None | $406.92 |
Browse Plan Formulary |
PHP (HMO SNP)
|
$0.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
25% | n/a | None | $341.42 |
Browse Plan Formulary |
Preferred Choice Dade (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$40.00 | $110.00 | None | $366.92 |
Browse Plan Formulary |
Preferred Special Care Miami-Dade (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$45.00 | $125.00 | None | $366.92 |
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 |
Simply Level (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | n/a | None | $271.16 |
Browse Plan Formulary |
Simply More (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | n/a | None | $271.16 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP ONE (Regional PPO SNP)
|
$0.00 |
$405 |
to be determined |
4 |
Tier 4 |
$0.00 | n/a | None | $340.70 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$50.00 | $125.00 | None | $349.72 |
Browse Plan Formulary |
WellCare Essential (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$75.00 | $187.50 | None | $349.72 |
Browse Plan Formulary |
WellCare Guardian (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$50.00 | $125.00 | None | $349.72 |
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 |
CareNeeds PLUS (HMO SNP)
|
$6.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:240 /30Days | $292.07 |
Browse Plan Formulary |
CareNeeds (HMO SNP)
|
$11.20 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:240 /30Days | $292.07 |
Browse Plan Formulary |
CareExtra (HMO)
|
$12.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
24% | 24% | Q:240 /30Days | $292.07 |
Browse Plan Formulary |
Preferred Medicare Assist (HMO SNP)
|
$16.00 |
$405 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | n/a | None | $358.04 |
Browse Plan Formulary |
Humana Value Plus H1036-264 (HMO)
|
$16.30 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
24% | 24% | Q:240 /30Days | $292.07 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-077A (HMO SNP)
|
$17.40 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:240 /30Days | $292.07 |
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 |
UnitedHealthcare Dual Complete RP (Regional PPO SNP)
|
$19.80 |
$405 |
to be determined |
4 |
Tier 4 |
15% | n/a | None | $340.70 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-257 (HMO SNP)
|
$21.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:240 /30Days | $292.07 |
Browse Plan Formulary |
Coventry Medicare Summit Plan (HMO SNP)
|
$21.40 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | None | $164.49 |
Browse Plan Formulary |
UnitedHealthcare Assisted Living Plan (PPO SNP)
|
$21.40 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $355.89 |
Browse Plan Formulary |
WellCare Select (HMO SNP)
|
$22.40 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $349.72 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax Plus (HMO SNP)
|
$25.20 |
$405 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | n/a | None | $358.04 |
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 |
WellCare Access (HMO SNP)
|
$28.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $349.72 |
Browse Plan Formulary |
Allwell Dual Medicare (HMO SNP)
|
$29.00 |
$405 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | None | $349.96 |
Browse Plan Formulary |
BlueMedicare Complete (HMO SNP)
|
$29.10 |
$405* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$0.00 | n/a | None | $358.22 |
Browse Plan Formulary |
Coventry Medicare Vista Plan (HMO SNP)
|
$29.10 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | None | $146.30 |
Browse Plan Formulary |
Freedom Medi-Medi Full (HMO SNP)
|
$29.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Drug |
$95.00 | n/a | None | $402.74 |
Browse Plan Formulary |
Freedom Medi-Medi Partial (HMO SNP)
|
$29.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | None | $402.74 |
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 |
HealthSun MediMax (HMO)
|
$29.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
25% | n/a | None | $438.11 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$29.10 |
$405 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
47% | n/a | None | $304.54 |
Browse Plan Formulary |
Optimum Emerald Full (HMO SNP)
|
$29.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Drug |
$95.00 | n/a | None | $402.74 |
Browse Plan Formulary |
Optimum Emerald Partial (HMO SNP)
|
$29.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Drug |
$95.00 | n/a | None | $402.74 |
Browse Plan Formulary |
Simply Care (HMO SNP)
|
$29.10 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | n/a | None | $271.16 |
Browse Plan Formulary |
Simply Comfort (HMO SNP)
|
$29.10 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | n/a | None | $271.16 |
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 |
Simply Complete (HMO SNP)
|
$29.10 |
$405* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$0.00 | n/a | None | $271.16 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$29.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | None | $354.66 |
Browse Plan Formulary |
WellCare Liberty (HMO SNP)
|
$29.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $349.72 |
Browse Plan Formulary |
HumanaChoice R5826-005 (Regional PPO)
|
$33.60 |
$100 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:240 /30Days | $292.07 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$34.90 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | None | $350.92 |
Browse Plan Formulary |
BlueMedicare Choice (Regional PPO)
|
$41.00 |
$260 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | n/a | None | $358.07 |
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 |
HumanaChoice H5216-065 (PPO)
|
$57.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:240 /30Days | $292.07 |
Browse Plan Formulary |
Humana Gold Choice H8145-061 (PFFS)
|
$117.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:240 /30Days | $292.07 |
Browse Plan Formulary |