SYMBICORT 160-4.5MCG HFA AEROSOL WITH ADAPTER (120 INHL) (NDC: 00186037020)
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 | 3 |
Tier 3 |
25% | 25% | Q:31 /90Days | $278.25 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | Q:31 /90Days | $278.18 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | Q:31 /90Days | $278.68 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | Q:31 /90Days | $278.13 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | Q:31 /90Days | $278.71 |
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 Value (HMO-POS)
|
$7.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $280.56 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $280.56 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $280.13 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $280.34 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $279.98 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $280.36 |
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 | 3 |
Tier 3 |
25% | 25% | Q:31 /90Days | $278.24 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | Q:31 /90Days | $278.71 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | Q:31 /90Days | $278.18 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | Q:31 /90Days | $278.81 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | Q:31 /90Days | $278.15 |
Browse Plan Formulary |
HumanaChoice R5826-006 (Regional PPO)
|
$28.20 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | Q:11 /30Days | $277.53 |
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)
|
$30.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $280.36 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$30.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $280.56 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$30.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $280.13 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$30.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $280.34 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$30.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $279.98 |
Browse Plan Formulary |
Fidelis Secure Comfort (HMO SNP)
|
$30.40 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | P Q:10 /30Days | $279.85 |
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 |
Fidelis Secure Freedom (HMO SNP)
|
$31.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$35.00 | $70.00 | P Q:10 /30Days | $279.85 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | Q:31 /90Days | $278.18 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | Q:31 /90Days | $278.81 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | Q:31 /90Days | $278.15 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | Q:31 /90Days | $278.24 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$40.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | Q:31 /90Days | $278.71 |
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 H5216-009 (PPO)
|
$67.00 |
$320* | Yes, but No Gap Coverage for this drug. | 3* |
Preferred Brand |
$45.00 | $125.00 | Q:11 /30Days | $277.79 |
Browse Plan Formulary |
Humana Gold Choice H8145-005 (PFFS)
|
$83.00 |
$320* | Yes, but No Gap Coverage for this drug. | 3* |
Preferred Brand |
$45.00 | $125.00 | Q:11 /30Days | $277.96 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$91.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | Q:31 /90Days | $278.71 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$91.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | Q:31 /90Days | $278.13 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$91.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | Q:31 /90Days | $278.25 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$91.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | Q:31 /90Days | $278.18 |
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)
|
$91.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | Q:31 /90Days | $278.68 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$95.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $100.00 | None | $280.56 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$109.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $100.00 | None | $280.36 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$109.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $100.00 | None | $280.56 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$109.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $100.00 | None | $279.98 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$109.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $100.00 | None | $280.34 |
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)
|
$109.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $100.00 | None | $280.13 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$110.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | Q:31 /90Days | $278.18 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$110.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | Q:31 /90Days | $278.71 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$110.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | Q:31 /90Days | $278.81 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$110.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | Q:31 /90Days | $278.15 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$110.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | Q:31 /90Days | $278.24 |
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)
|
$182.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | Q:31 /90Days | $278.71 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$182.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | Q:31 /90Days | $278.24 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$182.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | Q:31 /90Days | $278.18 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$182.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | Q:31 /90Days | $278.81 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$182.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | Q:31 /90Days | $278.15 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$196.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $87.50 | Q:31 /90Days | $278.71 |
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)
|
$196.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $87.50 | Q:31 /90Days | $278.13 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$196.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $87.50 | Q:31 /90Days | $278.68 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$196.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $87.50 | Q:31 /90Days | $278.18 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$196.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $87.50 | Q:31 /90Days | $278.25 |
Browse Plan Formulary |