PENTASA 500MG CAPSULE (120 BOT) (NDC: 54092019112)
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-POS Basic (HMO-POS)
|
$0.00 |
$395 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | None | $1,404.24 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | None | $1,403.19 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | None | $1,407.51 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | None | $1,400.91 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | None | $1,420.54 |
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 |
HAP Senior Plus (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | n/a | None | $1,545.43 |
Browse Plan Formulary |
MeridianCare Essential (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$100.00 | n/a | None | $1,473.71 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | n/a | None | $1,444.24 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | n/a | None | $1,437.50 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | n/a | None | $1,426.87 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | n/a | None | $1,436.35 |
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 | 3 |
Preferred Brand |
$42.00 | n/a | None | $1,438.10 |
Browse Plan Formulary |
HAP Senior Plus Option 1 (PPO)
|
$15.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
25% | n/a | None | $1,545.43 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | n/a | None | $1,426.87 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | n/a | None | $1,436.35 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | n/a | None | $1,438.10 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | n/a | None | $1,437.50 |
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 | 3 |
Preferred Brand |
$42.00 | n/a | None | $1,444.24 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$24.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,418.28 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$24.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,400.40 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$24.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,410.58 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$24.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,407.77 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$24.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,404.24 |
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 | 4 |
Non-Preferred Brand |
25% | n/a | None | $1,473.71 |
Browse Plan Formulary |
HAP Senior Plus Option 1 (HMO-POS)
|
$45.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$100.00 | n/a | None | $1,545.43 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$72.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | n/a | None | $1,426.87 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$82.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | n/a | None | $1,444.24 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$82.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | n/a | None | $1,426.87 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$82.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | n/a | None | $1,437.50 |
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)
|
$82.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | n/a | None | $1,438.10 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$82.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | n/a | None | $1,436.35 |
Browse Plan Formulary |
HAP Senior Plus Option 2 (HMO-POS)
|
$85.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$100.00 | n/a | None | $1,545.43 |
Browse Plan Formulary |
Paramount Elite - Enhanced Medical and Drug (HMO)
|
$85.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | None | $1,439.21 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$86.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,400.40 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$86.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,418.28 |
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)
|
$86.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,404.24 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$86.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,410.58 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$86.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,407.77 |
Browse Plan Formulary |
HAP Senior Plus Option 2 (PPO)
|
$118.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$100.00 | n/a | None | $1,545.43 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$145.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | 45% | None | $1,420.54 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$145.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | 45% | None | $1,400.91 |
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)
|
$145.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | 45% | None | $1,407.51 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$145.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | 45% | None | $1,404.24 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$145.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | 45% | None | $1,403.19 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$160.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$38.00 | n/a | None | $1,426.87 |
Browse Plan Formulary |
HAP Senior Plus Option 3 (HMO-POS)
|
$170.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$100.00 | n/a | None | $1,545.43 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$171.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | n/a | None | $1,444.24 |
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)
|
$171.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | n/a | None | $1,437.50 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$171.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | n/a | None | $1,426.87 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$171.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | n/a | None | $1,436.35 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$171.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | n/a | None | $1,438.10 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$179.50 |
$105 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,418.28 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$179.50 |
$105 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,400.40 |
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 |
Medicare Plus Blue PPO Signature (PPO)
|
$179.50 |
$105 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,404.24 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$179.50 |
$105 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,407.77 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$179.50 |
$105 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,410.58 |
Browse Plan Formulary |
HAP Senior Plus Option 3 (PPO)
|
$190.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$100.00 | n/a | None | $1,545.43 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$269.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$38.00 | $114.00 | None | $1,404.24 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$269.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$38.00 | $114.00 | None | $1,407.77 |
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)
|
$269.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$38.00 | $114.00 | None | $1,410.58 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$269.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$38.00 | $114.00 | None | $1,400.40 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$269.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$38.00 | $114.00 | None | $1,418.28 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$306.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | 45% | None | $1,420.54 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$306.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | 45% | None | $1,400.91 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$306.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | 45% | None | $1,407.51 |
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)
|
$306.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | 45% | None | $1,403.19 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$306.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | 45% | None | $1,404.24 |
Browse Plan Formulary |