TRIENTINE HCL 250 MG CAPSULE [Syprine] (100 ) (NDC: 00591491001)
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 |
BCN Advantage HMO HealthyValue (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | None | $4,541.73 |
Browse Plan Formulary |
BCN Advantage HMO HealthyValue (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | None | $4,541.73 |
Browse Plan Formulary |
BCN Advantage HMO HealthyValue (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | None | $4,541.73 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $4,541.73 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $4,541.73 |
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 |
5 |
Specialty Tier |
25% | n/a | None | $4,541.73 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $4,541.73 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $4,541.73 |
Browse Plan Formulary |
HAP Senior Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $4,321.16 |
Browse Plan Formulary |
Humana Gold Plus H8908-004 (HMO)
|
$0.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $5,469.87 |
Browse Plan Formulary |
MeridianCare Enhanced (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | n/a | None | $4,866.09 |
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 Essential (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | n/a | None | $4,866.09 |
Browse Plan Formulary |
HAP Senior Plus Option 1 (PPO)
|
$15.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $4,321.16 |
Browse Plan Formulary |
HumanaChoice R3887-002 (Regional PPO)
|
$20.00 |
$405 |
to be determined |
5 |
Specialty Tier |
25% | n/a | None | $5,469.87 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$23.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | None | $4,541.73 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$23.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | None | $4,541.73 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$23.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | None | $4,541.73 |
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)
|
$24.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $4,541.73 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$24.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $4,541.73 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$24.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $4,541.73 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$24.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $4,541.73 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$24.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $4,541.73 |
Browse Plan Formulary |
Humana Value Plus H5216-133 (PPO)
|
$26.90 |
$280 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | n/a | None | $5,469.87 |
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 Guardian (HMO-POS SNP)
|
$32.80 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P Q:240 /30Days | $4,933.33 |
Browse Plan Formulary |
MeridianCare Extra (HMO SNP)
|
$33.30 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | n/a | None | $4,866.09 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$33.30 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $5,162.86 |
Browse Plan Formulary |
HAP Senior Plus Option 1 (HMO-POS)
|
$45.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $4,321.16 |
Browse Plan Formulary |
Humana Gold Plus H8908-001 (HMO)
|
$47.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $5,469.87 |
Browse Plan Formulary |
MeridianCare Elite (HMO)
|
$47.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | n/a | None | $4,866.09 |
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)
|
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P Q:240 /30Days | $4,933.33 |
Browse Plan Formulary |
BCN Advantage HMO ConnectedCare (HMO)
|
$56.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,541.73 |
Browse Plan Formulary |
HAP Senior Plus Henry Ford Tiered Access (HMO)
|
$60.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $4,321.16 |
Browse Plan Formulary |
HAP Senior Plus Option 2 (HMO-POS)
|
$85.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $4,321.16 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$92.00 |
$115 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | None | $6,149.70 |
Browse Plan Formulary |
HumanaChoice H5216-011 (PPO)
|
$106.00 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | None | $5,469.87 |
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)
|
$109.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $4,541.73 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$109.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $4,541.73 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$109.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $4,541.73 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$109.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $4,541.73 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$109.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $4,541.73 |
Browse Plan Formulary |
HAP Senior Plus Option 2 (PPO)
|
$118.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $4,321.16 |
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 |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$164.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,541.73 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$164.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,541.73 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$164.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,541.73 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$164.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,541.73 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$164.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,541.73 |
Browse Plan Formulary |
HAP Senior Plus Option 3 (HMO-POS)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $4,321.16 |
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 |
Medicare Plus Blue PPO Signature (PPO)
|
$172.50 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | None | $4,541.73 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$172.50 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | None | $4,541.73 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$172.50 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | None | $4,541.73 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$172.50 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | None | $4,541.73 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$172.50 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | None | $4,541.73 |
Browse Plan Formulary |
HAP Senior Plus Option 3 (PPO)
|
$190.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $4,321.16 |
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 |
Erickson Advantage Champion (HMO-POS SNP)
|
$196.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P Q:240 /30Days | $4,933.33 |
Browse Plan Formulary |
Erickson Advantage Signature with Drugs (HMO-POS)
|
$196.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P Q:240 /30Days | $4,933.33 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$301.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,541.73 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$301.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,541.73 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$301.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,541.73 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$301.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,541.73 |
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)
|
$301.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,541.73 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$312.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,541.73 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$312.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,541.73 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$312.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,541.73 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$312.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,541.73 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$312.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,541.73 |
Browse Plan Formulary |