SELZENTRY 25 MG TABLET (NDC: 49702023308)
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 | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:180 /30Days | $537.68 |
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 | Q:240 /30Days | $543.98 |
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 | Q:240 /30Days | $543.98 |
Browse Plan Formulary |
Allwell Medicare (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$0.00 | n/a | None | $539.99 |
Browse Plan Formulary |
Allwell Medicare Premier (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$20.00 | n/a | None | $539.99 |
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 | $538.09 |
Browse Plan Formulary |
BlueMedicare Classic (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$93.00 | n/a | Q:240 /30Days | $517.73 |
Browse Plan Formulary |
BlueMedicare Premier (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$65.00 | n/a | Q:240 /30Days | $517.73 |
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 | $500.68 |
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 | $500.68 |
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 | Q:240 /30Days | $543.98 |
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 | Q:240 /30Days | $543.98 |
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 | $507.39 |
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 | $507.39 |
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 | $507.39 |
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 | $507.39 |
Browse Plan Formulary |
HealthSun SunPlus Advantage Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$25.00 | n/a | None | $498.66 |
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 | $500.70 |
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 | $500.70 |
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 | $500.70 |
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 | $500.70 |
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 | $500.70 |
Browse Plan Formulary |
Leon Medical Centers Health Plans - Leon Cares (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Brand |
$0.00 | n/a | None | $523.95 |
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 |
Medica HealthCare Plans MedicareMax (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$30.00 | $80.00 | Q:180 /30Days | $537.68 |
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 | $507.39 |
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 | $507.39 |
Browse Plan Formulary |
PHP (HMO SNP)
|
$0.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
25% | n/a | None | $504.44 |
Browse Plan Formulary |
Preferred Choice Dade (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$0.00 | $0.00 | Q:180 /30Days | $537.68 |
Browse Plan Formulary |
Preferred Special Care Miami-Dade (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$15.00 | $35.00 | Q:180 /30Days | $537.68 |
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. | 4 |
Non-Preferred Brand |
$10.00 | n/a | Q:120 /30Days | $513.68 |
Browse Plan Formulary |
Simply More (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$5.00 | n/a | Q:120 /30Days | $513.68 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP ONE (Regional PPO SNP)
|
$0.00 |
$405 | to be determined | 3 |
Tier 3 |
$0.00 | n/a | Q:180 /30Days | $537.68 |
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 | $547.84 |
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 | $547.84 |
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 | $547.84 |
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 |
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 | $500.68 |
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 | $500.68 |
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 | $500.68 |
Browse Plan Formulary |
Preferred Medicare Assist (HMO SNP)
|
$16.00 |
$405 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
25% | n/a | Q:180 /30Days | $537.68 |
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 | $500.70 |
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 | $500.70 |
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 | 3 |
Tier 3 |
15% | n/a | Q:180 /30Days | $537.68 |
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 | $500.70 |
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 | Q:240 /30Days | $544.99 |
Browse Plan Formulary |
UnitedHealthcare Assisted Living Plan (PPO SNP)
|
$21.40 |
$200* | No additional gap coverage, only the Donut Hole Discount | 3* |
Preferred Brand |
$47.00 | $131.00 | Q:180 /30Days | $537.68 |
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 | $547.84 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax Plus (HMO SNP)
|
$25.20 |
$405 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
25% | n/a | Q:180 /30Days | $537.68 |
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 | $547.84 |
Browse Plan Formulary |
Allwell Dual Medicare (HMO SNP)
|
$29.00 |
$405 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | n/a | None | $539.99 |
Browse Plan Formulary |
BlueMedicare Complete (HMO SNP)
|
$29.10 |
$405 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$100.00 | n/a | Q:240 /30Days | $518.21 |
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 | Q:240 /30Days | $544.99 |
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 | $507.39 |
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 | $507.39 |
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 | 4 |
Non-Preferred Brand |
25% | n/a | None | $498.66 |
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 | $541.67 |
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 | $507.39 |
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 | $507.39 |
Browse Plan Formulary |
Simply Care (HMO SNP)
|
$29.10 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$35.00 | n/a | Q:120 /30Days | $513.68 |
Browse Plan Formulary |
Simply Comfort (HMO SNP)
|
$29.10 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$35.00 | n/a | Q:120 /30Days | $513.68 |
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. | 4 |
Non-Preferred Brand |
$75.00 | n/a | Q:120 /30Days | $512.76 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$29.10 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | n/a | Q:180 /30Days | $537.68 |
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 | $547.84 |
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 | $500.70 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$34.90 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | n/a | Q:180 /30Days | $537.68 |
Browse Plan Formulary |
BlueMedicare Choice (Regional PPO)
|
$41.00 |
$260 | to be determined | 4 |
Non-Preferred Brand |
$100.00 | n/a | Q:240 /30Days | $517.73 |
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 |
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 | $500.70 |
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 | $500.70 |
Browse Plan Formulary |