CALQUENCE 100 MG CAPSULE (NDC: 00310051260)
2019 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 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | 30% | P Q:60 /30Days | $15,030.50 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$195 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | 29% | P Q:60 /30Days | $15,030.50 |
Browse Plan Formulary |
Aetna Medicare Plus Plan (PPO)
|
$0.00 |
$345 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
26% | n/a | P | $14,834.40 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$0.00 |
$295 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
27% | n/a | P | $14,834.40 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
29% | n/a | P | $14,834.40 |
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 |
Amerigroup Medicare-Medicaid Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | 0% | P | $14,146.10 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $14,127.80 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $14,127.80 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $14,127.80 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $14,127.80 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $14,127.80 |
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. |
5 |
Specialty Tier |
33% | n/a | P | $14,127.80 |
Browse Plan Formulary |
Amerivantage COPD (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $14,127.80 |
Browse Plan Formulary |
Amerivantage Diabetes (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $14,127.80 |
Browse Plan Formulary |
Amerivantage Heart (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $14,127.80 |
Browse Plan Formulary |
Amerivantage Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $14,127.80 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Basic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | P Q:60 /30Days | $14,403.40 |
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 |
Cigna-HealthSpring Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $15,046.00 |
Browse Plan Formulary |
Humana Gold Plus H0028-038 (HMO)
|
$0.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
26% | n/a | P Q:60 /30Days | $14,329.90 |
Browse Plan Formulary |
Humana Gold Plus H0028-042 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $14,329.90 |
Browse Plan Formulary |
Imperial Insurance Company of Texas Traditional (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $14,720.40 |
Browse Plan Formulary |
Imperial Insurance Company of Texas Value HMO SNP (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $14,720.40 |
Browse Plan Formulary |
KelseyCare Advantage Rx (HMO)
|
$0.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
32% | n/a | P Q:60 /30Days | $14,514.80 |
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 |
Memorial Hermann Advantage (HMO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | n/a | P Q:60 /30Days | $14,606.00 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | 0% | P | $14,327.90 |
Browse Plan Formulary |
UnitedHealthcare Connected (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | 0% | P Q:60 /30Days | $15,030.50 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Choice (Regional PPO SNP)
|
$0.00 |
$415 |
to be determined |
5 |
All Formulary Drugs |
$0.00 | $0.00 | P Q:60 /30Days | $15,030.50 |
Browse Plan Formulary |
UnitedHealthcare Medicare Silver (Regional PPO SNP)
|
$0.00 |
$364 |
to be determined |
5 |
Specialty Tier |
25% | 25% | P Q:60 /30Days | $15,030.50 |
Browse Plan Formulary |
WellCare Dividend Prime (HMO)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | P | $15,256.70 |
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 |
WellCare TexanPlus Choice (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $15,256.70 |
Browse Plan Formulary |
WellCare TexanPlus Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $15,256.70 |
Browse Plan Formulary |
WellCare Value (HMO-POS)
|
$0.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
29% | n/a | P | $15,256.70 |
Browse Plan Formulary |
UnitedHealthcare Medicare Gold (Regional PPO SNP)
|
$6.50 |
$295 |
to be determined |
5 |
Specialty Tier |
27% | 27% | P Q:60 /30Days | $15,030.50 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$15.00 |
$245 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | P | $14,834.40 |
Browse Plan Formulary |
HumanaChoice H5216-043 (PPO)
|
$15.00 |
$295 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | n/a | P Q:60 /30Days | $14,329.90 |
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 H5216-043 (PPO)
|
$15.00 |
$295 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | n/a | P Q:60 /30Days | $14,329.90 |
Browse Plan Formulary |
Cigna-HealthSpring TotalCare (HMO SNP)
|
$17.70 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
5 |
All Formulary Drugs |
15% | 15% | P Q:60 /30Days | $15,046.00 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Choice Plus (PPO)
|
$20.00 |
$415 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | 25% | P Q:60 /30Days | $14,403.40 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$23.40 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
5 |
All Formulary Drugs |
15% | 15% | P Q:60 /30Days | $15,030.50 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H0028-031 (HMO SNP)
|
$23.90 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | n/a | P Q:60 /30Days | $14,329.90 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H0028-033 (HMO SNP)
|
$23.90 |
$365 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $14,329.90 |
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 R4182-004 (Regional PPO)
|
$23.90 |
$175 |
to be determined |
5 |
Specialty Tier |
29% | n/a | P Q:60 /30Days | $14,329.90 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO SNP)
|
$24.00 |
$415 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $14,127.80 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO SNP)
|
$24.00 |
$415 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $14,127.80 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO SNP)
|
$24.00 |
$415 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $14,127.80 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO SNP)
|
$24.00 |
$415 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $14,127.80 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO SNP)
|
$24.00 |
$415 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $14,127.80 |
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)
|
$24.00 |
$415 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $14,127.80 |
Browse Plan Formulary |
Amerivantage Dual Premier (HMO SNP)
|
$24.00 |
$415 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $14,127.80 |
Browse Plan Formulary |
Imperial Insurance Company of Texas Dual (HMO SNP) (HMO SNP)
|
$24.00 |
$415 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | Q:60 /30Days | $14,720.40 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$24.00 |
$415 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $15,064.10 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$24.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
5 |
All Formulary Drugs |
25% | 25% | P Q:60 /30Days | $15,030.50 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$24.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $15,256.70 |
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 |
WellCare Liberty (HMO SNP)
|
$24.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $15,256.70 |
Browse Plan Formulary |
WellCare TexanPlus Star (HMO SNP)
|
$24.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $15,256.70 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (Regional PPO)
|
$28.50 |
$325 |
to be determined |
5 |
Specialty Tier |
26% | 26% | P Q:60 /30Days | $15,030.50 |
Browse Plan Formulary |
Erickson Advantage Guardian (HMO-POS SNP)
|
$33.10 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P Q:60 /30Days | $15,030.50 |
Browse Plan Formulary |
HumanaChoice R4182-003 (Regional PPO)
|
$33.70 |
$175 |
to be determined |
5 |
Specialty Tier |
29% | n/a | P Q:60 /30Days | $14,329.90 |
Browse Plan Formulary |
Erickson Advantage Freedom (HMO-POS)
|
$48.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P Q:60 /30Days | $15,030.50 |
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 |
KelseyCare Advantage Rx+Choice (HMO-POS)
|
$77.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
32% | n/a | P Q:60 /30Days | $14,514.80 |
Browse Plan Formulary |
HumanaChoice H5216-042 (PPO)
|
$87.00 |
$175 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | P Q:60 /30Days | $14,329.90 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Choice Premier (PPO)
|
$90.00 |
$415 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | 25% | P Q:60 /30Days | $14,403.40 |
Browse Plan Formulary |
Humana Gold Choice H8145-084 (PFFS)
|
$116.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | P Q:60 /30Days | $14,329.90 |
Browse Plan Formulary |
Aetna Medicare Value Plan (PPO)
|
$150.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $14,834.40 |
Browse Plan Formulary |
Erickson Advantage Champion (HMO-POS SNP)
|
$195.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P Q:60 /30Days | $15,030.50 |
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 |
Erickson Advantage Signature with Drugs (HMO-POS)
|
$195.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P Q:60 /30Days | $15,030.50 |
Browse Plan Formulary |