ATOVAQUONE 750 MG/5 ML SUSP [Mepron] (210 ML ) (NDC: 65162069388)
2015 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
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 |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $1,018.45 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $1,018.45 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $1,018.45 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $1,018.45 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $1,018.45 |
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 |
Meridian Prime (HMO)
|
$0.00 |
$320* | No additional gap coverage, only the Donut Hole Discount | 2* |
Non-Preferred Generic |
$5.00 | $15.00 | None | $773.95 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $823.05 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $823.05 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $823.05 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $823.05 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $823.05 |
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)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $1,018.45 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $1,018.45 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $1,018.45 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $1,018.45 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $1,018.45 |
Browse Plan Formulary |
HumanaChoice R5826-006 (Regional PPO)
|
$28.20 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $1,142.29 |
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)
|
$28.60 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Specialty Tier |
25% | n/a | None | $1,170.92 |
Browse Plan Formulary |
Fidelis Secure Comfort (HMO SNP)
|
$30.40 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $806.31 |
Browse Plan Formulary |
Meridian Advantage Plan of Michigan (HMO SNP)
|
$31.40 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $773.95 |
Browse Plan Formulary |
Fidelis Secure Freedom (HMO SNP)
|
$31.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Specialty Tier |
25% | 25% | None | $806.31 |
Browse Plan Formulary |
McLaren Advantage Sapphire (HMO)
|
$36.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 4 |
Specialty Tier |
29% | n/a | None | $1,041.11 |
Browse Plan Formulary |
McLaren Advantage Sapphire (HMO)
|
$36.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 4 |
Specialty Tier |
29% | n/a | None | $1,041.11 |
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 ConnectedCare (HMO)
|
$41.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$15.00 | $37.50 | None | $1,018.45 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$55.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $893.08 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$58.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
31% | n/a | None | $823.05 |
Browse Plan Formulary |
McLaren Advantage Diamond (HMO)
|
$72.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 4 |
Specialty Tier |
29% | n/a | None | $1,041.11 |
Browse Plan Formulary |
McLaren Advantage Diamond (HMO)
|
$72.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 4 |
Specialty Tier |
29% | n/a | None | $1,041.11 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$75.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $1,018.45 |
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)
|
$75.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $1,018.45 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$75.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $1,018.45 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$75.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $1,018.45 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$75.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $1,018.45 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | None | $823.05 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | None | $823.05 |
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)
|
$95.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | None | $823.05 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | None | $823.05 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | None | $823.05 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$103.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $1,018.45 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$103.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $1,018.45 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$103.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $1,018.45 |
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)
|
$103.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $1,018.45 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$103.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $1,018.45 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$106.00 |
$100* | No additional gap coverage, only the Donut Hole Discount | 2* |
Non-Preferred Generic |
$15.00 | $37.50 | None | $893.08 |
Browse Plan Formulary |
Alliance Medicare PPO (PPO)
|
$126.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$15.00 | $37.50 | None | $893.08 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$146.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | None | $823.05 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$157.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
30% | n/a | None | $1,018.45 |
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)
|
$157.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
30% | n/a | None | $1,018.45 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$157.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
30% | n/a | None | $1,018.45 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$157.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
30% | n/a | None | $1,018.45 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$157.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
30% | n/a | None | $1,018.45 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$178.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | None | $823.05 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$178.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | None | $823.05 |
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)
|
$178.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | None | $823.05 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$178.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | None | $823.05 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$178.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | None | $823.05 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$192.00 |
$50* | Yes, but No Gap Coverage for this drug. | 2* |
Non-Preferred Generic |
$10.00 | $25.00 | None | $893.08 |
Browse Plan Formulary |
Alliance Medicare PPO (PPO)
|
$210.00 |
$150* | Yes, but No Gap Coverage for this drug. | 2* |
Non-Preferred Generic |
$10.00 | $25.00 | None | $893.08 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$232.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $1,018.45 |
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)
|
$232.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $1,018.45 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$232.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $1,018.45 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$232.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $1,018.45 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$232.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $1,018.45 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$244.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $1,018.45 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$244.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $1,018.45 |
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)
|
$244.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $1,018.45 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$244.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $1,018.45 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$244.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $1,018.45 |
Browse Plan Formulary |