FETZIMA ER 20 MG CAPSULE (30 EA ) (NDC: 00456222030)
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 Choice (PPO)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $420.67 |
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 | $419.58 |
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:180 /30Days | $401.53 |
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:180 /30Days | $401.53 |
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:2 /1Days | $401.47 |
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 |
AvMed Medicare Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $187.50 | P Q:180 /30Days | $395.08 |
Browse Plan Formulary |
AvMed Medicare Circle (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $187.50 | P Q:180 /30Days | $387.64 |
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 | $393.80 |
Browse Plan Formulary |
BlueMedicare Premier (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$93.00 | $279.00 | Q:30 /30Days | $390.47 |
Browse Plan Formulary |
CareFree (HMO)
|
$0.00 |
$100 |
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 |
CareOne (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 |
|
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 |
Coventry Medicare Summit Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | P Q:180 /30Days | $401.55 |
Browse Plan Formulary |
Devoted Health Broward (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $212.50 | P Q:180 /30Days | $388.53 |
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 | $390.73 |
Browse Plan Formulary |
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 | $390.19 |
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 | $390.92 |
Browse Plan Formulary |
HealthSun HealthAdvantage Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$15.00 | n/a | None | $401.88 |
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 |
Humana Gold Plus - Diabetes (HMO SNP)
|
$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 H1036-065C (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 H1036-237 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$80.00 | $230.00 | P Q:30 /30Days | $412.98 |
Browse Plan Formulary |
Humana Gold Plus H1036-237 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$80.00 | $230.00 | P Q:30 /30Days | $412.98 |
Browse Plan Formulary |
HumanaChoice Florida H5216-068 (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 | $411.83 |
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 |
Medica HealthCare Plans MedicareMax (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $419.80 |
Browse Plan Formulary |
MMM - ELITE (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $225.00 | P Q:180 /30Days | $386.10 |
Browse Plan Formulary |
MMM - EXTRA (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:180 /30Days | $386.11 |
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 | $391.24 |
Browse Plan Formulary |
Optimum Platinum Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Drug |
$65.00 | $130.00 | Q:30 /30Days | $391.24 |
Browse Plan Formulary |
PHP (HMO SNP)
|
$0.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
25% | n/a | Q:30 /30Days | $381.95 |
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 |
Preferred Choice Broward (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:30 /30Days | $419.80 |
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:180 /30Days | $387.36 |
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:180 /30Days | $387.36 |
Browse Plan Formulary |
Solis Health Plans (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | S Q:30 /30Days | $400.48 |
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 | $419.58 |
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:180 /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 |
WellCare Dividend (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $150.00 | P Q:180 /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 |
$90.00 | $180.00 | P Q:180 /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:180 /30Days | $397.42 |
Browse Plan Formulary |
WellCare Premier (PPO)
|
$0.00 |
$100 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | P Q:180 /30Days | $397.42 |
Browse Plan Formulary |
WellCare Value (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | P Q:180 /30Days | $397.42 |
Browse Plan Formulary |
CareExtra (HMO)
|
$11.90 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
24% | 24% | 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 |
CareNeeds PLUS (HMO SNP)
|
$18.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:30 /30Days | $412.98 |
Browse Plan Formulary |
CareNeeds (HMO SNP)
|
$18.20 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:30 /30Days | $412.98 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-103A (HMO SNP)
|
$22.20 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:30 /30Days | $412.98 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-255 (HMO SNP)
|
$23.10 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | P Q:30 /30Days | $412.98 |
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:180 /30Days | $397.42 |
Browse Plan Formulary |
WellCare Reserve (HMO SNP)
|
$25.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P Q:180 /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 |
UnitedHealthcare Dual Complete RP (Regional PPO SNP)
|
$25.30 |
$415 |
to be determined |
4 |
All Formulary Drugs |
15% | 15% | S Q:30 /30Days | $419.58 |
Browse Plan Formulary |
Coventry Medicare Summit Plan (HMO SNP)
|
$25.50 |
$415 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:180 /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:180 /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:180 /30Days | $397.42 |
Browse Plan Formulary |
Preferred Medicare Assist (HMO SNP)
|
$27.00 |
$415 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | 25% | S Q:30 /30Days | $420.47 |
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 | $419.91 |
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 |
Molina Medicare Options Plus (HMO SNP)
|
$30.20 |
$415 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
41% | 41% | P Q:180 /30Days | $388.55 |
Browse Plan Formulary |
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:2 /1Days | $388.53 |
Browse Plan Formulary |
BlueMedicare Complete (HMO SNP)
|
$30.30 |
$415 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$99.00 | $297.00 | Q:30 /30Days | $395.62 |
Browse Plan Formulary |
Devoted Health Prime Broward (HMO)
|
$30.30 |
$415 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | 25% | P Q:180 /30Days | $388.53 |
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 | $390.55 |
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 | $390.55 |
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 |
HealthSun MediMax (HMO)
|
$30.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | n/a | None | $401.11 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax Plus (HMO SNP)
|
$30.30 |
$415 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | 25% | S Q:30 /30Days | $420.47 |
Browse Plan Formulary |
MMM - PLATINUM (HMO SNP)
|
$30.30 |
$415 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:180 /30Days | $388.57 |
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 | $390.55 |
Browse Plan Formulary |
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 | $390.55 |
Browse Plan Formulary |
Simply Advantage (HMO SNP)
|
$30.30 |
$415 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$90.00 | n/a | P Q:180 /30Days | $387.37 |
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 |
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:180 /30Days | $387.36 |
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:180 /30Days | $387.36 |
Browse Plan Formulary |
Simply Complete (HMO SNP)
|
$30.30 |
$415 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$90.00 | n/a | P Q:180 /30Days | $387.37 |
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:180 /30Days | $387.36 |
Browse Plan Formulary |
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 | $419.90 |
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 | $411.83 |
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 |
BlueMedicare Choice (Regional PPO)
|
$41.00 |
$250 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $392.43 |
Browse Plan Formulary |
HumanaChoice H5216-065 (PPO)
|
$57.00 |
$350 |
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 |
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 |
BlueMedicare Select (PPO)
|
$147.80 |
$305 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:30 /30Days | $391.82 |
Browse Plan Formulary |