APTIOM 200 MG TABLET (30 EA ) (NDC: 63402020230)
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 |
Advantra Silver (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:180 /30Days | $936.84 |
Browse Plan Formulary |
BlueJourney Essential (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $908.36 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None | $914.12 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None | $941.68 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None | $918.84 |
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 |
Geisinger Gold Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $899.93 |
Browse Plan Formulary |
Geisinger Gold Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $899.93 |
Browse Plan Formulary |
Geisinger Gold Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $899.93 |
Browse Plan Formulary |
Geisinger Gold Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $915.56 |
Browse Plan Formulary |
Geisinger Gold Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $899.93 |
Browse Plan Formulary |
Geisinger Gold Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $899.93 |
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 |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $899.93 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $915.56 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $899.93 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $899.93 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $899.93 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $899.93 |
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 H6622-035 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $913.99 |
Browse Plan Formulary |
Humana Gold Plus H6622-043 (HMO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | n/a | P Q:30 /30Days | $914.02 |
Browse Plan Formulary |
UPMC for Life HMO Premier Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | P | $933.94 |
Browse Plan Formulary |
Vibra Health Plan Essential Coverage (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $927.62 |
Browse Plan Formulary |
AARP MedicareComplete (HMO)
|
$14.00 |
$230 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | 28% | Q:30 /30Days | $956.65 |
Browse Plan Formulary |
AdvantraOne (PPO)
|
$19.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:180 /30Days | $936.93 |
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)
|
$19.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | n/a | Q:30 /30Days | $985.98 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$23.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None | $921.97 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$23.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None | $918.84 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$23.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None | $909.66 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete ONE (HMO SNP)
|
$23.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | n/a | Q:30 /30Days | $985.98 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H6622-038 (HMO SNP)
|
$25.00 |
$230 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | P Q:30 /30Days | $913.95 |
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 Assisted Living Plan (PPO SNP)
|
$29.30 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | 29% | Q:30 /30Days | $989.14 |
Browse Plan Formulary |
HumanaChoice R0923-002 (Regional PPO)
|
$29.40 |
$315 |
to be determined |
5 |
Specialty Tier |
26% | n/a | P Q:30 /30Days | $913.88 |
Browse Plan Formulary |
Advantra Cares (HMO SNP)
|
$31.10 |
$130 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | n/a | Q:180 /30Days | $936.72 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 2 (PPO SNP)
|
$32.70 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | n/a | Q:30 /30Days | $989.40 |
Browse Plan Formulary |
Advantra Silver Plus (HMO)
|
$36.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:180 /30Days | $936.84 |
Browse Plan Formulary |
HumanaChoice H5525-006 (PPO)
|
$37.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $914.02 |
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 |
UPMC for Life Dual (HMO SNP)
|
$37.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
46% | n/a | P | $899.36 |
Browse Plan Formulary |
AmeriHealth Caritas VIP Care (HMO SNP)
|
$37.20 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | n/a | S Q:30 /30Days | $907.72 |
Browse Plan Formulary |
Gateway Health Medicare Assured Diamond (HMO SNP)
|
$37.20 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | n/a | Q:30 /30Days | $903.55 |
Browse Plan Formulary |
Gateway Health Medicare Assured Ruby (HMO SNP)
|
$37.20 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | Q:30 /30Days | $903.55 |
Browse Plan Formulary |
Geisinger Gold Secure Rx (HMO SNP)
|
$37.20 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | P Q:30 /30Days | $899.93 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $899.93 |
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 |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $905.12 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $899.93 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $899.93 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $899.93 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $899.93 |
Browse Plan Formulary |
BlueJourney Value (HMO)
|
$48.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $908.36 |
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 |
Vibra Health Plan Enhanced Coverage (PPO)
|
$55.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $927.62 |
Browse Plan Formulary |
Aetna Medicare Silver Plan (HMO)
|
$56.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:180 /30Days | $936.90 |
Browse Plan Formulary |
BlueJourney Classic (PPO)
|
$62.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $908.36 |
Browse Plan Formulary |
Humana Gold Choice H8145-052 (PFFS)
|
$63.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $913.98 |
Browse Plan Formulary |
Freedom Blue PPO ValueRx (PPO)
|
$73.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None | $918.05 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$77.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $899.93 |
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 |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$77.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $899.93 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$77.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $899.93 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$77.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $915.56 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$77.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $899.93 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$77.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $899.93 |
Browse Plan Formulary |
UPMC for Life HMO Rx (HMO)
|
$81.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | n/a | P | $933.94 |
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 |
Advantra Silver Plus (PPO)
|
$86.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:180 /30Days | $936.82 |
Browse Plan Formulary |
HumanaChoice H5216-120 (PPO)
|
$117.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $914.02 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$126.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:180 /30Days | $936.92 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$135.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | n/a | P | $933.94 |
Browse Plan Formulary |
BlueJourney Premier (HMO)
|
$148.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $908.36 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$149.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $899.93 |
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 |
Geisinger Gold Classic Advantage Rx (HMO)
|
$149.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $899.93 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$149.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $899.93 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$149.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $905.12 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$149.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $899.93 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$149.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P Q:30 /30Days | $899.93 |
Browse Plan Formulary |
Aetna Medicare Gold Plan (PPO)
|
$156.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:180 /30Days | $936.90 |
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 |
BlueJourney Prime (PPO)
|
$169.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $908.36 |
Browse Plan Formulary |
Freedom Blue PPO Standard (PPO)
|
$188.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None | $918.05 |
Browse Plan Formulary |
Freedom Blue PPO Deluxe (PPO)
|
$291.50 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None | $918.05 |
Browse Plan Formulary |