FETZIMA ER 120 MG CAPSULE (30 EA ) (NDC: 00456221230)
2019 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
See your cost using a drug discount card: Compare prices at pharmacies near you |
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 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | S Q:30 /30Days | $418.67 |
Browse Plan Formulary |
AARP MedicareComplete Choice (PPO)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | S Q:30 /30Days | $418.67 |
Browse Plan Formulary |
AARP MedicareComplete Choice Plan 2 (Regional PPO)
|
$0.00 |
$395 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $419.64 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (HMO-POS)
|
$0.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $401.46 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$0.00 |
$295 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $401.46 |
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 |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $401.55 |
Browse Plan Formulary |
Allwell Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:1 /1Days | $400.16 |
Browse Plan Formulary |
BlueMedicare Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | Q:30 /30Days | $392.96 |
Browse Plan Formulary |
CareFree (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$85.00 | $245.00 | P Q:30 /30Days | $412.98 |
Browse Plan Formulary |
CareOne PLUS (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $245.00 | P Q:30 /30Days | $412.98 |
Browse Plan Formulary |
Cigna-HealthSpring Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | S Q:30 /30Days | $421.07 |
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 |
Devoted Health Central Florida (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | P Q:30 /30Days | $388.47 |
Browse Plan Formulary |
FHCP Medicare Premier Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $282.00 | P | $407.80 |
Browse Plan Formulary |
Florida Hospital SunSaver Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $225.00 | P Q:30 /30Days | $384.61 |
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 | $170.00 | Q:30 /30Days | $390.98 |
Browse Plan Formulary |
Freedom Platinum Plan Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Drug |
$70.00 | $140.00 | Q:30 /30Days | $390.44 |
Browse Plan Formulary |
Freedom VIP Care (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Drug |
$60.00 | $120.00 | Q:30 /30Days | $391.08 |
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 |
Freedom VIP Savings (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Drug |
$80.00 | $160.00 | Q:30 /30Days | $391.06 |
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 | $160.00 | Q:30 /30Days | $391.06 |
Browse Plan Formulary |
Humana Gold Plus H1036-146 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $245.00 | P Q:30 /30Days | $412.98 |
Browse Plan Formulary |
Humana Gold Plus H1036-269 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P Q:30 /30Days | $412.98 |
Browse Plan Formulary |
HumanaChoice Florida H5216-072 (PPO)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days | $412.98 |
Browse Plan Formulary |
HumanaChoice R5826-074 (Regional PPO)
|
$0.00 |
$395 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days | $412.98 |
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 |
Optimum Diamond Rewards (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Drug |
$80.00 | $160.00 | Q:30 /30Days | $390.68 |
Browse Plan Formulary |
Optimum Diamond Rewards COPD (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Drug |
$80.00 | $160.00 | Q:30 /30Days | $390.55 |
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 | $170.00 | Q:30 /30Days | $390.70 |
Browse Plan Formulary |
Simply Level (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$75.00 | n/a | P Q:30 /30Days | $385.58 |
Browse Plan Formulary |
Simply More (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$75.00 | n/a | P Q:30 /30Days | $385.58 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP ONE (Regional PPO SNP)
|
$0.00 |
$415 |
to be determined |
4 |
All Formulary Drugs |
$0.00 | $0.00 | S Q:30 /30Days | $419.64 |
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 Dividend (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $150.00 | P Q:30 /30Days | $397.42 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $150.00 | P Q:30 /30Days | $397.42 |
Browse Plan Formulary |
WellCare Dividend Prime (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:30 /30Days | $397.42 |
Browse Plan Formulary |
WellCare Elite (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $150.00 | P Q:30 /30Days | $397.42 |
Browse Plan Formulary |
WellCare Essential (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $150.00 | P Q:30 /30Days | $397.42 |
Browse Plan Formulary |
WellCare Premier (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | P Q:30 /30Days | $397.42 |
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 TotalCare (HMO SNP)
|
$8.40 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
All Formulary Drugs |
15% | 15% | S Q:30 /30Days | $421.07 |
Browse Plan Formulary |
CareNeeds (HMO SNP)
|
$14.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days | $412.98 |
Browse Plan Formulary |
CareNeeds PLUS (HMO SNP)
|
$15.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days | $412.98 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete LP (HMO SNP)
|
$21.60 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
All Formulary Drugs |
15% | 15% | S Q:30 /30Days | $419.24 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$23.80 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $397.42 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-213 (HMO SNP)
|
$25.30 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days | $412.98 |
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 |
UnitedHealthcare Dual Complete RP (Regional PPO SNP)
|
$25.30 |
$415 |
to be determined |
4 |
All Formulary Drugs |
15% | 15% | S Q:30 /30Days | $419.64 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO SNP)
|
$25.40 |
$415 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $401.57 |
Browse Plan Formulary |
WellCare Liberty (HMO SNP)
|
$26.60 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $397.42 |
Browse Plan Formulary |
WellCare Select (HMO SNP)
|
$26.80 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $397.42 |
Browse Plan Formulary |
WellCare Reserve (HMO SNP)
|
$26.90 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:30 /30Days | $397.42 |
Browse Plan Formulary |
UnitedHealthcare Assisted Living Plan (PPO SNP)
|
$27.70 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $419.80 |
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 |
Allwell Dual Medicare (HMO SNP)
|
$30.30 |
$415 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | S Q:1 /1Days | $388.53 |
Browse Plan Formulary |
Devoted Health Prime Central Florida (HMO)
|
$30.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | P Q:30 /30Days | $388.47 |
Browse Plan Formulary |
Freedom Medi-Medi Full (HMO SNP)
|
$30.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $391.18 |
Browse Plan Formulary |
Freedom Medi-Medi Partial (HMO SNP)
|
$30.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $391.18 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-247 (HMO SNP)
|
$30.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days | $412.98 |
Browse Plan Formulary |
Optimum Emerald Full (HMO SNP)
|
$30.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $391.18 |
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 |
Optimum Emerald Partial (HMO SNP)
|
$30.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $391.18 |
Browse Plan Formulary |
Simply Advantage (HMO SNP)
|
$30.30 |
$415 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | n/a | P Q:30 /30Days | $386.46 |
Browse Plan Formulary |
Simply Care (HMO SNP)
|
$30.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
25% | n/a | P Q:30 /30Days | $385.58 |
Browse Plan Formulary |
Simply Comfort (HMO SNP)
|
$30.30 |
$415 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
25% | n/a | P Q:30 /30Days | $385.58 |
Browse Plan Formulary |
Simply Complete (HMO SNP)
|
$30.30 |
$415 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | n/a | P Q:30 /30Days | $386.46 |
Browse Plan Formulary |
Simply Select (HMO)
|
$30.30 |
$415 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
25% | n/a | P Q:30 /30Days | $385.58 |
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 Nursing Home Plan (PPO SNP)
|
$30.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
All Formulary Drugs |
25% | 25% | S Q:30 /30Days | $419.55 |
Browse Plan Formulary |
HumanaChoice R5826-005 (Regional PPO)
|
$31.30 |
$100 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P Q:30 /30Days | $412.98 |
Browse Plan Formulary |
BlueMedicare Choice (Regional PPO)
|
$41.00 |
$250 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $392.21 |
Browse Plan Formulary |
HumanaChoice Florida H7284-001 (PPO)
|
$75.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days | $412.98 |
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 | P Q:30 /30Days | $412.98 |
Browse Plan Formulary |