OXYCODON-ACETAMINOPHEN 2.5-325 (100.000 EA ) (NDC: 00603497821)
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 Plan 1 (HMO)
|
$0.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $172.46 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$225* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $172.46 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $121.00 | Q:180 /30Days | $111.49 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $121.00 | Q:180 /30Days | $133.26 |
Browse Plan Formulary |
Amerigroup Medicare-Medicaid Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | Q:360 /30Days | $181.72 |
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 |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | Q:360 /30Days | $173.53 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | Q:360 /30Days | $152.53 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | Q:360 /30Days | $154.90 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | Q:360 /30Days | $166.51 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | Q:360 /30Days | $166.51 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | Q:360 /30Days | $203.22 |
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 |
Amerivantage Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | Q:360 /30Days | $158.27 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Basic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:360 /30Days | $173.58 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Basic Plus (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:360 /30Days | $173.58 |
Browse Plan Formulary |
Care Improvement Plus Dual Advantage (Regional PPO SNP)
|
$0.00 |
$405 |
to be determined |
3 |
Tier 3 |
$0.00 | n/a | Q:360 /30Days | $170.84 |
Browse Plan Formulary |
Care Improvement Plus Silver Rx (Regional PPO SNP)
|
$0.00 |
$340 |
to be determined |
3 |
Preferred Brand |
25% | n/a | Q:360 /30Days | $170.84 |
Browse Plan Formulary |
Cigna-HealthSpring Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | n/a | Q:360 /30Days | $163.84 |
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 H2649-052 (HMO)
|
$0.00 |
$360* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $231.33 |
Browse Plan Formulary |
Humana Gold Plus H2649-064 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $231.33 |
Browse Plan Formulary |
KelseyCare Advantage Rx (HMO)
|
$0.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$17.00 | n/a | None | $174.11 |
Browse Plan Formulary |
Memorial Hermann Advantage (HMO)
|
$0.00 |
$300* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | n/a | None | $367.52 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | n/a | Q:360 /30Days | $185.17 |
Browse Plan Formulary |
TexanPlus Choice (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $5.00 | Q:360 /30Days | $184.95 |
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 |
TexanPlus Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $5.00 | Q:360 /30Days | $184.95 |
Browse Plan Formulary |
UnitedHealthcare Connected (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | n/a | Q:360 /30Days | $172.45 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $117.50 | Q:360 /30Days | $184.95 |
Browse Plan Formulary |
WellCare Dividend Prime (HMO)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $117.50 | Q:360 /30Days | $184.95 |
Browse Plan Formulary |
WellCare Value (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$30.00 | $75.00 | Q:360 /30Days | $184.95 |
Browse Plan Formulary |
WellCare Value (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$30.00 | $75.00 | Q:360 /30Days | $184.95 |
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 |
Care Improvement Plus Gold Rx (Regional PPO SNP)
|
$4.60 |
$295* |
to be determined |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $170.85 |
Browse Plan Formulary |
HumanaChoice H5216-043 (PPO)
|
$15.00 |
$360* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $248.80 |
Browse Plan Formulary |
HumanaChoice H5216-043 (PPO)
|
$15.00 |
$360* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $221.70 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$16.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $121.00 | Q:180 /30Days | $111.49 |
Browse Plan Formulary |
Cigna-HealthSpring TotalCare (HMO SNP)
|
$17.80 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | Q:360 /30Days | $163.84 |
Browse Plan Formulary |
WellCare Liberty (HMO SNP)
|
$19.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $117.50 | Q:360 /30Days | $184.95 |
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 |
UnitedHealthcare Dual Complete (HMO SNP)
|
$20.40 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | n/a | Q:360 /30Days | $173.11 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$20.80 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $117.50 | Q:360 /30Days | $184.95 |
Browse Plan Formulary |
HumanaChoice R4182-004 (Regional PPO)
|
$24.00 |
$175 |
to be determined |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $222.88 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO SNP)
|
$24.60 |
$405 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | Q:360 /30Days | $203.22 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO SNP)
|
$24.60 |
$405 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | Q:360 /30Days | $173.53 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO SNP)
|
$24.60 |
$405 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | Q:360 /30Days | $152.53 |
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 |
Amerivantage Dual Coordination (HMO SNP)
|
$24.60 |
$405 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | Q:360 /30Days | $154.90 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO SNP)
|
$24.60 |
$405 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | Q:360 /30Days | $166.51 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO SNP)
|
$24.60 |
$405 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | Q:360 /30Days | $166.51 |
Browse Plan Formulary |
Amerivantage Dual Premier (HMO SNP)
|
$24.60 |
$405 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | Q:360 /30Days | $158.27 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H2649-048 (HMO SNP)
|
$24.60 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $219.11 |
Browse Plan Formulary |
Humana Kidney Care (HMO-POS SNP)
|
$24.60 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $231.33 |
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 |
Molina Medicare Options Plus (HMO SNP)
|
$24.60 |
$405 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$43.00 | n/a | Q:360 /30Days | $185.19 |
Browse Plan Formulary |
TexanPlus Star (HMO SNP)
|
$24.60 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | Q:360 /30Days | $184.95 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$24.60 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | n/a | Q:360 /30Days | $170.51 |
Browse Plan Formulary |
Memorial Hermann Advantage (PPO)
|
$25.00 |
$300* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | n/a | None | $367.52 |
Browse Plan Formulary |
Care Improvement Plus Medicare Advantage (Regional PPO)
|
$26.70 |
$290 |
to be determined |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $170.85 |
Browse Plan Formulary |
Erickson Advantage Guardian (HMO-POS SNP)
|
$32.80 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$28.00 | $74.00 | Q:360 /30Days | $163.90 |
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 R4182-003 (Regional PPO)
|
$34.30 |
$175 |
to be determined |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $222.88 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Choice Plus (PPO)
|
$42.00 |
$405 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:360 /30Days | $173.58 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Premier (HMO)
|
$47.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:360 /30Days | $173.58 |
Browse Plan Formulary |
Erickson Advantage Freedom (HMO-POS)
|
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:360 /30Days | $163.90 |
Browse Plan Formulary |
KelseyCare Advantage Rx+Choice (HMO-POS)
|
$77.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$17.00 | n/a | None | $174.11 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Choice Premier (PPO)
|
$83.00 |
$405 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:360 /30Days | $173.58 |
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 H5216-042 (PPO)
|
$87.00 |
$175 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $216.17 |
Browse Plan Formulary |
Humana Gold Choice H8145-084 (PFFS)
|
$116.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $220.90 |
Browse Plan Formulary |
Aetna Medicare Value Plan (PPO)
|
$123.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $121.00 | Q:180 /30Days | $111.49 |
Browse Plan Formulary |
Erickson Advantage Champion (HMO-POS SNP)
|
$196.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:360 /30Days | $163.90 |
Browse Plan Formulary |
Erickson Advantage Signature with Drugs (HMO-POS)
|
$196.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:360 /30Days | $163.90 |
Browse Plan Formulary |