Incivek 375mg/1 4 BOX per CARTON / 7 BLISTER PACK in 1 BOX / 6 FILM COATED TABLETS in BLISTER PA (4 BOX in 1 CARTON / 7 BLI ) (NDC: 51167010001)
2014 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 |
AARP MedicareComplete Choice Plan 2 (Regional PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P | $24,206.10 |
Browse Plan Formulary |
AARP MedicareComplete Plus (HMO-POS)
|
$0.00 |
$0 |
Few Generics |
5 |
Specialty Tier |
33% | 33% | P | $24,216.60 |
Browse Plan Formulary |
Amerivantage Classic+ Rx Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P | $24,122.30 |
Browse Plan Formulary |
AvMed Medicare Choice (HMO)
|
$0.00 |
$0 |
Many Generics |
5 |
Specialty Tier |
33% | n/a | P Q:168 /28Days | $24,492.90 |
Browse Plan Formulary |
BlueMedicare HMO LifeTime (HMO)
|
$0.00 |
$0 |
Many Generics |
5 |
Specialty Tier |
33% | 33% | P | $24,072.60 |
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 HMO PrimeTime (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P | $24,072.60 |
Browse Plan Formulary |
BlueMedicare Regional PPO (Regional PPO)
|
$0.00 |
$30 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | P | $24,075.90 |
Browse Plan Formulary |
CareDirect (HMO SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | P Q:168 /28Days | $24,160.80 |
Browse Plan Formulary |
CareFree PLUS (HMO)
|
$0.00 |
$0 |
Few Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | P Q:168 /28Days | $24,160.80 |
Browse Plan Formulary |
CareHeart (HMO SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | P Q:168 /28Days | $24,160.80 |
Browse Plan Formulary |
CareOne (HMO)
|
$0.00 |
$0 |
Some Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | P Q:168 /28Days | $24,160.80 |
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 |
Clear Skies (HMO SNP)
|
$0.00 |
$0 |
All Generics |
4 |
Specialty Tier |
33% | 33% | None | $24,810.20 |
Browse Plan Formulary |
Coventry Summit Ideal (HMO)
|
$0.00 |
$0 |
Many Generics |
4 |
Specialty Tier |
33% | n/a | P Q:180 /30Days | $24,447.40 |
Browse Plan Formulary |
Coventry Vista Ideal (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | n/a | P Q:180 /30Days | $24,447.40 |
Browse Plan Formulary |
Day Break (HMO)
|
$0.00 |
$0 |
All Generics |
4 |
Specialty Tier |
33% | 33% | None | $24,810.20 |
Browse Plan Formulary |
Freedom Medicare Plan Rx (HMO)
|
$0.00 |
$0 |
Many Generics |
4 |
Specialty Tier |
33% | 33% | P | $23,403.80 |
Browse Plan Formulary |
Freedom VIP Savings (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | 33% | P | $23,415.80 |
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 COPD (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | 33% | P | $23,409.60 |
Browse Plan Formulary |
Healthy Advantage Plan (HMO)
|
$0.00 |
$0 |
Many Generics |
5 |
Specialty Tier |
33% | n/a | P | $23,965.50 |
Browse Plan Formulary |
Humana Gold Plus H1036-065C (HMO)
|
$0.00 |
$0 |
Some Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | P Q:168 /28Days | $24,160.80 |
Browse Plan Formulary |
Humana Gold Plus H1036-224 (HMO)
|
$0.00 |
$0 |
Few Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | P Q:168 /28Days | $24,160.80 |
Browse Plan Formulary |
Humana Gold Plus SNP-CVD/CHF H1036-186 (HMO SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | P Q:168 /28Days | $24,160.80 |
Browse Plan Formulary |
Humana Gold Plus SNP-DB H1036-121C (HMO SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | P Q:168 /28Days | $24,160.80 |
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 R5826-074 (Regional PPO)
|
$0.00 |
$150 |
Few Generics, Few Brands |
5 |
Specialty Tier |
29% | n/a | P Q:168 /28Days | $24,095.20 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax (HMO)
|
$0.00 |
$0 |
Many Generics |
4 |
Specialty Tier |
33% | n/a | P | $24,216.60 |
Browse Plan Formulary |
Optimum Gold Rewards Plan (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | 33% | P | $23,422.30 |
Browse Plan Formulary |
Optimum Platinum Plan (HMO-POS)
|
$0.00 |
$0 |
Many Generics |
4 |
Specialty Tier |
33% | 33% | P | $23,422.30 |
Browse Plan Formulary |
PHP (HMO SNP)
|
$0.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
25% | n/a | P | $23,885.90 |
Browse Plan Formulary |
Preferred Choice Broward (HMO)
|
$0.00 |
$0 |
Many Generics |
4 |
Specialty Tier |
33% | 33% | P | $24,216.60 |
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 Clear (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
25% | n/a | P | $23,610.10 |
Browse Plan Formulary |
Simply Extra (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $23,608.60 |
Browse Plan Formulary |
Simply Level (HMO SNP)
|
$0.00 |
$0 |
Many Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | P | $23,608.60 |
Browse Plan Formulary |
Simply More (HMO)
|
$0.00 |
$0 |
Many Generics |
5 |
Specialty Tier |
33% | n/a | P | $23,608.60 |
Browse Plan Formulary |
Simply Options (HMO-POS)
|
$0.00 |
$0 |
Many Generics |
5 |
Specialty Tier |
33% | n/a | P | $23,608.60 |
Browse Plan Formulary |
SunPlus Advantage Plan (HMO)
|
$0.00 |
$0 |
All Generics, All Brands |
5 |
Specialty Tier |
25% | n/a | P | $23,965.50 |
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 |
SunPlus Diabetes Special Needs Plan (HMO SNP)
|
$0.00 |
$0 |
All Generics, All Brands |
5 |
Specialty Tier |
25% | n/a | P | $23,965.50 |
Browse Plan Formulary |
Sunrise (HMO)
|
$0.00 |
$0 |
All Generics |
4 |
Specialty Tier |
33% | 33% | None | $24,810.20 |
Browse Plan Formulary |
Humana Gold Plus SNP-I H1036-185 (HMO SNP)
|
$7.70 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:168 /28Days | $24,160.80 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-103A (HMO SNP)
|
$8.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:168 /28Days | $24,160.80 |
Browse Plan Formulary |
WellCare Liberty (HMO SNP)
|
$9.40 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:504 /365Days | $24,534.90 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$10.40 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:504 /365Days | $24,534.90 |
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 |
Humana Gold Plus SNP-DE H1036-162 (HMO SNP)
|
$10.50 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:168 /28Days | $24,160.80 |
Browse Plan Formulary |
WellCare Select (HMO SNP)
|
$11.60 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:504 /365Days | $24,536.90 |
Browse Plan Formulary |
CareNeeds PLUS (HMO SNP)
|
$11.70 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:168 /28Days | $24,160.80 |
Browse Plan Formulary |
CareNeeds (HMO SNP)
|
$17.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:168 /28Days | $24,160.80 |
Browse Plan Formulary |
Coventry Summit Maximum (HMO SNP)
|
$18.90 |
$0 |
Many Generics |
4 |
Specialty Tier |
33% | n/a | P Q:180 /30Days | $23,907.60 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$19.80 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $24,206.20 |
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 |
Medica HealthCare Plans MedicareMax Plus (HMO-POS SNP)
|
$20.60 |
$0 |
Many Generics |
4 |
Specialty Tier |
25% | n/a | P | $24,215.30 |
Browse Plan Formulary |
Advantage by Sunshine Health (HMO SNP)
|
$21.00 |
$310 |
Many Generics |
2 |
Preferred Brand |
$45.00 | $45.00 | None | $24,286.30 |
Browse Plan Formulary |
Preferred Medicare Assist (HMO-POS SNP)
|
$21.20 |
$0 |
Many Generics |
4 |
Specialty Tier |
25% | 25% | P | $24,215.30 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP (Regional PPO SNP)
|
$21.80 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | P | $24,206.10 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$22.00 |
$310 |
Many Generics, Few Brands |
4 |
Specialty Tier |
25% | n/a | P | $24,135.90 |
Browse Plan Formulary |
Amerivantage Specialty + Rx (HMO SNP)
|
$22.10 |
$310 |
Some Generics |
5 |
Specialty Tier |
25% | 25% | P | $24,122.30 |
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 Vista Maximum Choice (HMO SNP)
|
$22.10 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | n/a | P Q:180 /30Days | $23,970.20 |
Browse Plan Formulary |
Freedom Medi-Medi Full (HMO SNP)
|
$22.10 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
n/a | n/a | P | $23,408.30 |
Browse Plan Formulary |
Freedom Medi-Medi Partial (HMO SNP)
|
$22.10 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P | $23,408.30 |
Browse Plan Formulary |
MediMax (HMO)
|
$22.10 |
$310 |
Call plan for details |
5 |
Specialty Tier |
25% | n/a | P | $23,960.90 |
Browse Plan Formulary |
Optimum Emerald Full (HMO SNP)
|
$22.10 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
n/a | n/a | P | $23,407.60 |
Browse Plan Formulary |
Optimum Emerald Partial (HMO SNP)
|
$22.10 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P | $23,407.60 |
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)
|
$22.10 |
$0 |
Many Generics |
5 |
Specialty Tier |
33% | n/a | P | $23,608.60 |
Browse Plan Formulary |
Simply Comfort (HMO SNP)
|
$22.10 |
$0 |
Many Generics |
5 |
Specialty Tier |
33% | n/a | P | $23,608.60 |
Browse Plan Formulary |
Simply Complete (HMO SNP)
|
$22.10 |
$310 |
Many Generics |
5 |
Specialty Tier |
25% | n/a | P | $23,608.60 |
Browse Plan Formulary |
Touch Institutional Special Needs Plan (HMO SNP)
|
$22.10 |
$310 |
Some Generics |
5 |
Specialty Tier |
25% | 25% | P | $24,141.30 |
Browse Plan Formulary |
Sunny Days (HMO SNP)
|
$33.90 |
$0 |
All Generics |
4 |
Specialty Tier |
25% | 25% | None | $24,810.20 |
Browse Plan Formulary |
HumanaChoice R5826-005 (Regional PPO)
|
$36.60 |
$0 |
Few Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | P Q:168 /28Days | $24,095.20 |
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 |
HumanaChoice H5415-056 (PPO)
|
$45.00 |
$0 |
Few Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | P Q:168 /28Days | $24,137.20 |
Browse Plan Formulary |
Humana Gold Choice H8145-061 (PFFS)
|
$103.00 |
$0 |
Few Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | P Q:168 /28Days | $24,092.10 |
Browse Plan Formulary |
BlueMedicare PPO (PPO)
|
$127.00 |
$0 |
Many Generics |
5 |
Specialty Tier |
33% | 33% | P | $24,060.70 |
Browse Plan Formulary |