JALYN 0.5MG/0.4MG CAPSULES (90 BOT ) (NDC: 00173080959)
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 |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $172.43 |
Browse Plan Formulary |
AvMed Medicare Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$25.00 | $75.00 | Q:30 /30Days | $171.39 |
Browse Plan Formulary |
BlueMedicare HMO LifeTime (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$25.00 | $75.00 | Q:30 /30Days | $172.36 |
Browse Plan Formulary |
CareDirect (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$5.00 | $5.00 | Q:30 /30Days | $170.72 |
Browse Plan Formulary |
CareFree PLUS (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | $95.00 | Q:30 /30Days | $170.72 |
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 |
CareHeart (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$5.00 | $5.00 | Q:30 /30Days | $170.72 |
Browse Plan Formulary |
CareOne PLUS (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$0.00 | $0.00 | Q:30 /30Days | $170.72 |
Browse Plan Formulary |
Coventry Summit Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Preferred Brand |
$0.00 | $0.00 | Q:30 /30Days | $172.61 |
Browse Plan Formulary |
Coventry Vista Ideal (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Preferred Brand |
$5.00 | $10.00 | Q:30 /30Days | $172.61 |
Browse Plan Formulary |
Freedom Medicare Plan Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Preferred Brand |
$35.00 | $70.00 | Q:30 /30Days | $169.31 |
Browse Plan Formulary |
Freedom VIP Care (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Preferred Brand |
$25.00 | $50.00 | Q:30 /30Days | $169.26 |
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 |
Freedom VIP Savings (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Preferred Brand |
$30.00 | $60.00 | Q:30 /30Days | $169.26 |
Browse Plan Formulary |
Freedom VIP Savings COPD (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Preferred Brand |
$30.00 | $60.00 | Q:30 /30Days | $169.26 |
Browse Plan Formulary |
HealthSun SunPlus Advantage Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$0.00 | n/a | None | $169.93 |
Browse Plan Formulary |
HealthSun SunPlus Advantage POS (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$0.00 | n/a | None | $169.93 |
Browse Plan Formulary |
Humana Gold Plus - Diabetes (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$5.00 | $5.00 | Q:30 /30Days | $170.72 |
Browse Plan Formulary |
Humana Gold Plus - Heart (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$5.00 | $5.00 | Q:30 /30Days | $170.72 |
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 H1036-054C (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$5.00 | $5.00 | Q:30 /30Days | $170.72 |
Browse Plan Formulary |
Humana Gold Plus H1036-237 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days | $171.20 |
Browse Plan Formulary |
Humana Gold Plus H1036-237 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days | $170.72 |
Browse Plan Formulary |
HumanaChoice R5826-074 (Regional PPO)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days | $170.80 |
Browse Plan Formulary |
Leon Medical Centers Health Plans - Leon Cares (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand |
$0.00 | n/a | None | $174.55 |
Browse Plan Formulary |
Optimum Gold Rewards Plan (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$30.00 | $60.00 | Q:30 /30Days | $169.20 |
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 |
Optimum Platinum Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Preferred Brand |
$10.00 | $20.00 | Q:30 /30Days | $169.20 |
Browse Plan Formulary |
Simply Extra (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$55.00 | n/a | None | $169.95 |
Browse Plan Formulary |
Simply Level (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$15.00 | n/a | None | $169.95 |
Browse Plan Formulary |
Simply More (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$15.00 | n/a | None | $169.95 |
Browse Plan Formulary |
WellCare Dividend (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$25.00 | $62.50 | Q:30 /30Days | $175.73 |
Browse Plan Formulary |
WellCare Essential (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$20.00 | $50.00 | Q:30 /30Days | $176.14 |
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 (HMO SNP)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days | $170.72 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-077A (HMO SNP)
|
$15.10 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days | $170.72 |
Browse Plan Formulary |
WellCare Select (HMO SNP)
|
$19.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:30 /30Days | $175.92 |
Browse Plan Formulary |
BlueMedicare Regional PPO (Regional PPO)
|
$20.20 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days | $172.43 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$20.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:30 /30Days | $175.73 |
Browse Plan Formulary |
Coventry Summit Maximum (HMO SNP)
|
$24.60 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days | $172.40 |
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 Liberty (HMO SNP)
|
$24.60 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:30 /30Days | $175.73 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$24.80 |
$320* |
Yes, but No Gap Coverage for this drug. |
2* |
Preferred Brand |
$0.00 | $0.00 | Q:30 /30Days | $171.40 |
Browse Plan Formulary |
Coventry Vista Maximum (HMO SNP)
|
$25.80 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days | $172.43 |
Browse Plan Formulary |
Freedom Medi-Medi Full (HMO SNP)
|
$25.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $169.34 |
Browse Plan Formulary |
Freedom Medi-Medi Partial (HMO SNP)
|
$25.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $169.34 |
Browse Plan Formulary |
HealthSun MediMax (HMO)
|
$25.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | n/a | None | $170.13 |
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 Full (HMO SNP)
|
$25.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $169.32 |
Browse Plan Formulary |
Optimum Emerald Partial (HMO SNP)
|
$25.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $169.32 |
Browse Plan Formulary |
Simply Care (HMO SNP)
|
$25.80 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$35.00 | n/a | None | $169.95 |
Browse Plan Formulary |
Simply Comfort (HMO SNP)
|
$25.80 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$35.00 | n/a | None | $169.95 |
Browse Plan Formulary |
Simply Complete (HMO SNP)
|
$25.80 |
$320 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$75.00 | n/a | None | $169.95 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$35.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | Q:30 /30Days | $172.43 |
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 R5826-005 (Regional PPO)
|
$39.40 |
$100 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $110.00 | Q:30 /30Days | $170.80 |
Browse Plan Formulary |
HumanaChoice H5415-056 (PPO)
|
$43.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days | $170.85 |
Browse Plan Formulary |
Humana Gold Choice H8145-061 (PFFS)
|
$101.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days | $170.83 |
Browse Plan Formulary |
Aetna Medicare Select Plus Plan (HMO)
|
$139.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days | $172.43 |
Browse Plan Formulary |
Aetna Medicare Select Plus Plan (PPO)
|
$139.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:30 /30Days | $172.43 |
Browse Plan Formulary |