REVLIMID 15MG CAPSULE 21 BOT (21 BOT) (NDC: 59572041521)
2016 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 Better Health Premier Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Brand Drugs |
0% | 0% | P Q:30 /30Days | $16,281.67 |
Browse Plan Formulary |
AmeriHealth Caritas VIP Care PLUS (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Brand Drugs |
0% | 0% | P | $16,567.72 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | P | $15,897.90 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | P | $15,897.90 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | P | $16,844.78 |
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 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | P | $16,844.78 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | P | $15,897.90 |
Browse Plan Formulary |
Fidelis SecureLife (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Brand Drugs |
0% | 0% | P | $16,238.51 |
Browse Plan Formulary |
HAP Midwest MI Health Link (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Brand Drugs |
0% | n/a | P Q:21 /28Days | $17,102.65 |
Browse Plan Formulary |
Harbor Medicare (HMO)
|
$0.00 |
$240 | to be determined | 5 |
Specialty Tier |
27% | n/a | P Q:30 /30Days | $16,447.89 |
Browse Plan Formulary |
HealthPlus MedicarePlus Option 0 (HMO)
|
$0.00 |
$360 | to be determined | 5 |
Specialty Tier |
25% | 25% | P | $16,030.10 |
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 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P | $16,157.75 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Brand Drugs |
0% | 0% | P | $16,324.93 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | P Q:30 /30Days | $16,270.01 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | P Q:30 /30Days | $16,789.72 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | P Q:30 /30Days | $16,789.72 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | P Q:30 /30Days | $16,168.12 |
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 |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | P Q:30 /30Days | $16,168.12 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | P Q:30 /30Days | $16,168.12 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | P Q:30 /30Days | $16,168.12 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | P Q:30 /30Days | $16,789.72 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | P Q:30 /30Days | $16,789.72 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | P Q:30 /30Days | $16,270.01 |
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)
|
$20.50 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $15,897.90 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$20.50 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $15,897.90 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$20.50 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $16,844.78 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$20.50 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $16,844.78 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$20.50 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $15,897.90 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$33.00 |
$360 | to be determined | 5 |
Specialty Tier |
25% | n/a | P | $16,332.35 |
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 |
HAP Midwest Health Plan (HMO SNP)
|
$33.50 |
$360 | to be determined | 2 |
Brand |
25% | n/a | P Q:21 /28Days | $17,122.77 |
Browse Plan Formulary |
Meridian Advantage Plan of Michigan (HMO SNP)
|
$33.50 |
$360 | to be determined | 1 |
Tier 1 |
$0.00 | $0.00 | P | $16,157.75 |
Browse Plan Formulary |
BCN Advantage HMO ConnectedCare (HMO)
|
$47.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | P | $15,897.90 |
Browse Plan Formulary |
Harbor Medicare Select (HMO)
|
$47.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $16,447.89 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$59.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | 33% | P | $17,835.52 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$66.00 |
$75 | to be determined | 5 |
Tier 5 |
31% | n/a | P Q:30 /30Days | $16,270.01 |
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 |
HAP Senior Plus - Henry Ford (HMO)
|
$79.00 |
$200 | to be determined | 5 |
Specialty Tier |
28% | 28% | P | $17,835.52 |
Browse Plan Formulary |
McLaren Advantage Sapphire (HMO)
|
$81.00 |
$150 | to be determined | 4 |
Specialty Tier |
29% | n/a | P Q:21 /28Days | $17,122.77 |
Browse Plan Formulary |
McLaren Advantage Sapphire (HMO)
|
$81.00 |
$150 | to be determined | 4 |
Specialty Tier |
29% | n/a | P Q:21 /28Days | $17,088.48 |
Browse Plan Formulary |
Humana Gold Plus H8908-001 (HMO)
|
$89.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | P Q:28 /28Days | $16,103.49 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75 | to be determined | 5 |
Tier 5 |
31% | n/a | P Q:30 /30Days | $16,270.01 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75 | to be determined | 5 |
Tier 5 |
31% | n/a | P Q:30 /30Days | $16,789.72 |
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 |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75 | to be determined | 5 |
Tier 5 |
31% | n/a | P Q:30 /30Days | $16,789.72 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75 | to be determined | 5 |
Tier 5 |
31% | n/a | P Q:30 /30Days | $16,168.12 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75 | to be determined | 5 |
Tier 5 |
31% | n/a | P Q:30 /30Days | $16,168.12 |
Browse Plan Formulary |
HealthPlus MedicarePlus Option 1 (HMO)
|
$98.00 |
$100* | to be determined | 5* |
Specialty Tier |
30% | 30% | P | $16,030.10 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$106.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $15,897.90 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$106.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $15,897.90 |
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)
|
$106.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $15,897.90 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$106.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $16,844.78 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$106.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $16,844.78 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$109.00 |
$100 | to be determined | 5 |
Specialty Tier |
30% | 30% | P | $17,835.52 |
Browse Plan Formulary |
McLaren Advantage Diamond (HMO)
|
$117.00 |
$150 | to be determined | 4 |
Specialty Tier |
29% | n/a | P Q:21 /28Days | $17,122.77 |
Browse Plan Formulary |
McLaren Advantage Diamond (HMO)
|
$117.00 |
$150 | to be determined | 4 |
Specialty Tier |
29% | n/a | P Q:21 /28Days | $17,088.48 |
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 R5826-006 (Regional PPO)
|
$121.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | P Q:28 /28Days | $16,102.11 |
Browse Plan Formulary |
Alliance Medicare PPO (PPO)
|
$126.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | 33% | P | $17,835.52 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$146.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $16,270.01 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$154.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | P | $15,897.90 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$154.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | P | $16,844.78 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$154.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | P | $16,844.78 |
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)
|
$154.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | P | $15,897.90 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$154.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | P | $15,897.90 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$169.00 |
$100 | to be determined | 5 |
Specialty Tier |
30% | n/a | None | $15,897.90 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$169.00 |
$100 | to be determined | 5 |
Specialty Tier |
30% | n/a | None | $15,897.90 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$169.00 |
$100 | to be determined | 5 |
Specialty Tier |
30% | n/a | None | $16,844.78 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$169.00 |
$100 | to be determined | 5 |
Specialty Tier |
30% | n/a | None | $16,844.78 |
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)
|
$169.00 |
$100 | to be determined | 5 |
Specialty Tier |
30% | n/a | None | $15,897.90 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$193.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $16,168.12 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$193.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $16,789.72 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$193.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $16,168.12 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$193.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $16,270.01 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$193.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $16,789.72 |
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 |
Alliance Medicare PPO (PPO)
|
$210.00 |
$150 | to be determined | 5 |
Specialty Tier |
29% | 29% | P | $17,835.52 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$220.00 |
$50 | to be determined | 5 |
Specialty Tier |
31% | 31% | P | $17,835.52 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$283.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | P | $15,897.90 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$283.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | P | $16,844.78 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$283.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | P | $16,844.78 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$283.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | P | $15,897.90 |
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)
|
$283.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | P | $15,897.90 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$294.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $16,844.78 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$294.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $16,844.78 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$294.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $15,897.90 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$294.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $15,897.90 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$294.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $15,897.90 |
Browse Plan Formulary |