DANTROLENE SODIUM 50MG CAPSULE (100 BOT) (NDC: 00115442201)
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 | None | $147.67 |
Browse Plan Formulary |
AARP MedicareComplete Choice Plan 2 (Regional PPO)
|
$0.00 |
$395 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $146.48 |
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 | None | $136.30 |
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 | None | $135.94 |
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 | None | $145.94 |
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 | None | $156.36 |
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 | None | $156.26 |
Browse Plan Formulary |
BlueMedicare Classic (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $30.00 | None | $146.77 |
Browse Plan Formulary |
BlueMedicare Premier (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $146.28 |
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 | None | $141.09 |
Browse Plan Formulary |
CareOne (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$20.00 | $50.00 | None | $141.09 |
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 | None | $133.41 |
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 | None | $156.35 |
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 | None | $145.17 |
Browse Plan Formulary |
Freedom VIP Savings (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Preferred Brand |
$30.00 | $60.00 | None | $144.14 |
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 | None | $144.14 |
Browse Plan Formulary |
Humana Gold Plus - Diabetes (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $110.00 | None | $141.09 |
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 H1036-065C (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$20.00 | $50.00 | None | $141.09 |
Browse Plan Formulary |
Humana Gold Plus H1036-237 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $110.00 | None | $141.09 |
Browse Plan Formulary |
Humana Gold Plus H1036-237 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $110.00 | None | $141.09 |
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 | None | $141.09 |
Browse Plan Formulary |
HumanaChoice R5826-074 (Regional PPO)
|
$0.00 |
$395 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $141.35 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $148.66 |
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 |
MMM - ELITE (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $156.35 |
Browse Plan Formulary |
MMM - EXTRA (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $60.00 | None | $156.35 |
Browse Plan Formulary |
Optimum Gold Rewards Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Preferred Brand |
$35.00 | $70.00 | None | $145.80 |
Browse Plan Formulary |
Optimum Platinum Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Preferred Brand |
$10.00 | $20.00 | None | $145.80 |
Browse Plan Formulary |
PHP (HMO SNP)
|
$0.00 |
$415 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
25% | n/a | None | $130.22 |
Browse Plan Formulary |
Preferred Choice Broward (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $148.66 |
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 Level (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $158.56 |
Browse Plan Formulary |
Simply More (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $158.56 |
Browse Plan Formulary |
Solis Health Plans (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $60.00 | None | $172.74 |
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 | None | $146.48 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $156.11 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $154.37 |
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 |
WellCare Dividend Prime (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $0.00 | None | $156.11 |
Browse Plan Formulary |
WellCare Elite (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $156.11 |
Browse Plan Formulary |
WellCare Premier (PPO)
|
$0.00 |
$100* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$0.00 | $0.00 | None | $156.11 |
Browse Plan Formulary |
WellCare Value (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $0.00 | None | $156.11 |
Browse Plan Formulary |
CareExtra (HMO)
|
$11.90 |
$415 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
24% | 24% | None | $141.09 |
Browse Plan Formulary |
CareNeeds PLUS (HMO SNP)
|
$18.00 |
$415 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $141.09 |
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)
|
$18.20 |
$415 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $141.09 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-103A (HMO SNP)
|
$22.20 |
$415 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $141.09 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-255 (HMO SNP)
|
$23.10 |
$415 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $141.09 |
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% | None | $155.20 |
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% | None | $156.11 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP (Regional PPO SNP)
|
$25.30 |
$415 | to be determined | 4 |
All Formulary Drugs |
15% | 15% | None | $146.48 |
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 |
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 | None | $133.21 |
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% | None | $155.20 |
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% | None | $154.95 |
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% | None | $147.67 |
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 | None | $146.12 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$30.20 |
$415 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
41% | 41% | None | $156.35 |
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 |
Allwell Dual Medicare (HMO SNP)
|
$30.30 |
$415 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $130.38 |
Browse Plan Formulary |
BlueMedicare Complete (HMO SNP)
|
$30.30 |
$415* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$0.00 | $0.00 | None | $146.31 |
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% | None | $156.35 |
Browse Plan Formulary |
Freedom Medi-Medi Full (HMO SNP)
|
$30.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$45.00 | $135.00 | None | $144.79 |
Browse Plan Formulary |
Freedom Medi-Medi Partial (HMO SNP)
|
$30.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$45.00 | $135.00 | None | $144.79 |
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% | None | $147.67 |
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 |
MMM - PLATINUM (HMO SNP)
|
$30.30 |
$415 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $156.35 |
Browse Plan Formulary |
Optimum Emerald Full (HMO SNP)
|
$30.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$45.00 | $135.00 | None | $144.79 |
Browse Plan Formulary |
Optimum Emerald Partial (HMO SNP)
|
$30.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$45.00 | $135.00 | None | $144.79 |
Browse Plan Formulary |
Simply Advantage (HMO SNP)
|
$30.30 |
$415* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$0.00 | $0.00 | None | $158.56 |
Browse Plan Formulary |
Simply Care (HMO SNP)
|
$30.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | None | $158.56 |
Browse Plan Formulary |
Simply Comfort (HMO SNP)
|
$30.30 |
$415 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | n/a | None | $158.56 |
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 Complete (HMO SNP)
|
$30.30 |
$415* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$0.00 | $0.00 | None | $158.56 |
Browse Plan Formulary |
Simply Select (HMO)
|
$30.30 |
$415* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$0.00 | $0.00 | None | $158.56 |
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% | None | $145.90 |
Browse Plan Formulary |
HumanaChoice R5826-005 (Regional PPO)
|
$31.30 |
$100 | to be determined | 4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $141.35 |
Browse Plan Formulary |
BlueMedicare Choice (Regional PPO)
|
$41.00 |
$250* | to be determined | 2* |
Generic |
$10.00 | $30.00 | None | $146.81 |
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 | None | $141.09 |
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 Choice H8145-061 (PFFS)
|
$117.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$97.00 | $281.00 | None | $141.31 |
Browse Plan Formulary |
BlueMedicare Select (PPO)
|
$147.80 |
$305 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $30.00 | None | $146.89 |
Browse Plan Formulary |