HAVRIX 1,440 UNITS/ML SYRINGE (NDC: 58160082652)
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 |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $136.00 | None | $142.53 |
Browse Plan Formulary |
BCN Advantage HMO HealthyValue (HMO)
|
$0.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $136.95 |
Browse Plan Formulary |
BCN Advantage HMO HealthyValue (HMO)
|
$0.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $136.14 |
Browse Plan Formulary |
BCN Advantage HMO HealthyValue (HMO)
|
$0.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $134.81 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $135.27 |
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 Basic (HMO-POS)
|
$0.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $135.88 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $136.21 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $135.87 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $134.85 |
Browse Plan Formulary |
MeridianCare Essential (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $40.00 | None | $140.54 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $105.00 | None | $136.91 |
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 |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $105.00 | None | $136.08 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $105.00 | None | $137.21 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $105.00 | None | $137.19 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $105.00 | None | $136.95 |
Browse Plan Formulary |
Humana Gold Plus H8908-002 (HMO)
|
$8.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $145.04 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$8.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $105.00 | None | $136.91 |
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 |
Aetna Medicare Value Plan (PPO)
|
$10.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $136.00 | None | $142.53 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$12.00 |
$100 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $136.95 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$12.00 |
$100 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $136.14 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$12.00 |
$100 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $134.81 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$14.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $105.00 | None | $136.91 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$14.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $105.00 | None | $136.08 |
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 |
PriorityMedicare Ideal (PPO)
|
$14.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $105.00 | None | $137.21 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$14.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $105.00 | None | $136.95 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$14.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $105.00 | None | $137.19 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$17.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $135.91 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$17.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $136.20 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$17.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $135.88 |
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 Essential (PPO)
|
$17.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $135.42 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$17.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $134.84 |
Browse Plan Formulary |
HumanaChoice H8087-001 (PPO)
|
$20.00 |
$195 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $145.04 |
Browse Plan Formulary |
HumanaChoice R3887-002 (Regional PPO)
|
$20.50 |
$150 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $145.04 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$24.50 |
$415 | No additional gap coverage, only the Donut Hole Discount | 3 |
All Formulary Drugs |
$0.00 | $0.00 | None | $148.80 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H8908-005 (HMO SNP)
|
$28.80 |
$250 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $145.04 |
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 |
Molina Medicare Options Plus (HMO SNP)
|
$30.10 |
$415 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $137.86 |
Browse Plan Formulary |
MeridianCare Extra (HMO SNP)
|
$32.90 |
$415 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
25% | 25% | None | $140.54 |
Browse Plan Formulary |
BCN Advantage HMO MyChoice Wellness (HMO)
|
$36.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $136.14 |
Browse Plan Formulary |
BCN Advantage HMO MyChoice Wellness (HMO)
|
$36.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $136.95 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$42.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $105.00 | None | $136.08 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$42.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $105.00 | None | $136.91 |
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 |
PriorityMedicare Merit (PPO)
|
$42.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $105.00 | None | $136.95 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$42.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $105.00 | None | $137.19 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$42.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $105.00 | None | $137.21 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$44.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $136.00 | None | $142.53 |
Browse Plan Formulary |
HumanaChoice H5216-009 (PPO)
|
$75.00 |
$105 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $145.04 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$78.00 |
$350 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $136.20 |
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)
|
$78.00 |
$350 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $135.88 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$78.00 |
$350 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $135.91 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$78.00 |
$350 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $135.42 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$78.00 |
$350 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $134.84 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$78.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$38.00 | $95.00 | None | $136.91 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$78.40 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$38.00 | $114.00 | None | $135.27 |
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)
|
$78.40 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$38.00 | $114.00 | None | $135.88 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$78.40 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$38.00 | $114.00 | None | $136.21 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$78.40 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$38.00 | $114.00 | None | $135.87 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$78.40 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$38.00 | $114.00 | None | $134.85 |
Browse Plan Formulary |
Humana Gold Choice H8145-006 (PFFS)
|
$94.00 |
$415 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $145.04 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$130.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $134.84 |
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 |
Medicare Plus Blue PPO Signature (PPO)
|
$130.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $135.42 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$130.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $135.91 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$130.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $136.20 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$130.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $135.88 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$137.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $92.50 | None | $137.21 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$137.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $92.50 | None | $137.19 |
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)
|
$137.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $92.50 | None | $136.95 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$137.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $92.50 | None | $136.08 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$137.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $92.50 | None | $136.91 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$180.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$38.00 | $114.00 | None | $136.21 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$180.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$38.00 | $114.00 | None | $135.88 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$180.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$38.00 | $114.00 | None | $135.27 |
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)
|
$180.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$38.00 | $114.00 | None | $134.85 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$180.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$38.00 | $114.00 | None | $135.87 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$263.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $111.00 | None | $135.88 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$263.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $111.00 | None | $136.20 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$263.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $111.00 | None | $135.91 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$263.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $111.00 | None | $135.42 |
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 |
Medicare Plus Blue PPO Assure (PPO)
|
$263.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $111.00 | None | $134.84 |
Browse Plan Formulary |