OXYCODONE HCL 100 MG/5 ML SOLN ORAL CONC [Roxicodone] (30 ML ) (NDC: 66689002530)
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. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:180 /30Days | $68.86 |
Browse Plan Formulary |
BCN Advantage HMO HealthyValue (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $109.26 |
Browse Plan Formulary |
BCN Advantage HMO HealthyValue (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $109.26 |
Browse Plan Formulary |
BCN Advantage HMO HealthyValue (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $110.22 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $109.44 |
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 |
4 |
Non-Preferred Drug |
50% | 50% | None | $108.80 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $109.26 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $109.96 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $109.12 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:180 /30Days | $90.52 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:180 /30Days | $90.34 |
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 |
4 |
Non-Preferred Drug |
45% | 45% | Q:180 /30Days | $95.04 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:180 /30Days | $94.56 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:180 /30Days | $92.89 |
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 | Q:270 /30Days | $157.85 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$8.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $60.37 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$8.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $101.71 |
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)
|
$8.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $93.00 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$8.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $89.74 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$8.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $70.58 |
Browse Plan Formulary |
Aetna Medicare Value Plan (PPO)
|
$10.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:180 /30Days | $68.86 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:180 /30Days | $94.56 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:180 /30Days | $92.89 |
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 |
4 |
Non-Preferred Drug |
45% | 45% | Q:180 /30Days | $90.52 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:180 /30Days | $90.34 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:180 /30Days | $95.04 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$15.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $109.26 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$15.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $110.22 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$15.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $109.26 |
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 H8087-001 (PPO)
|
$20.00 |
$195 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:270 /30Days | $157.91 |
Browse Plan Formulary |
HumanaChoice R3887-002 (Regional PPO)
|
$20.50 |
$150 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:270 /30Days | $157.91 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$27.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:180 /30Days | $95.04 |
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 | Q:270 /30Days | $157.89 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$38.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $93.00 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$38.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $89.74 |
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)
|
$38.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $70.58 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$38.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $60.37 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$38.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $101.71 |
Browse Plan Formulary |
BCN Advantage HMO MyChoice Wellness (HMO)
|
$41.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $110.22 |
Browse Plan Formulary |
BCN Advantage HMO MyChoice Wellness (HMO)
|
$41.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $109.26 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$44.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:180 /30Days | $68.86 |
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)
|
$62.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:180 /30Days | $92.89 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$62.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:180 /30Days | $90.52 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$62.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:180 /30Days | $95.04 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$62.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:180 /30Days | $90.34 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$62.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:180 /30Days | $94.56 |
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 | Q:270 /30Days | $157.93 |
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 |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$78.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $109.96 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$78.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $109.26 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$78.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $109.12 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$78.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $109.44 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$78.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $108.80 |
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 | Q:270 /30Days | $157.86 |
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 (HMO-POS)
|
$98.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | Q:180 /30Days | $95.04 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$110.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $101.71 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$110.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $93.00 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$110.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $89.74 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$110.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $70.58 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$110.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $60.37 |
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)
|
$150.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | Q:180 /30Days | $95.04 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$150.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | Q:180 /30Days | $94.56 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$150.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | Q:180 /30Days | $92.89 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$150.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | Q:180 /30Days | $90.52 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$150.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | Q:180 /30Days | $90.34 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$180.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $109.12 |
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 |
4 |
Non-Preferred Drug |
45% | 45% | None | $109.44 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$180.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $108.80 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$180.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $109.96 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$180.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $109.26 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$210.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $70.58 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$210.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $60.37 |
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)
|
$210.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $101.71 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$210.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $93.00 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$210.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $89.74 |
Browse Plan Formulary |