CEFPODOXIME PROXETIL FILM COATED TABLET 100MG (20 CT) (20 BOT) (NDC: 65862009520)
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 |
AARP MedicareComplete (HMO)
|
$0.00 |
$165 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $85.59 |
Browse Plan Formulary |
Advantra (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | None | $102.23 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
50% | 50% | None | $102.02 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $107.94 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $109.51 |
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 |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $107.47 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $107.07 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $112.07 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $108.85 |
Browse Plan Formulary |
Amerivantage Specialty + Rx (HMO SNP)
|
$0.00 |
$320 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $107.92 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Basic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$6.00 | $33.00 | None | $102.02 |
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 |
Care Improvement Plus Dual Advantage (Regional PPO SNP)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $86.67 |
Browse Plan Formulary |
Care Improvement Plus Gold Rx (PPO SNP)
|
$0.00 |
$315 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $86.01 |
Browse Plan Formulary |
Care Improvement Plus Gold Rx (Regional PPO SNP)
|
$0.00 |
$315 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $86.67 |
Browse Plan Formulary |
Care Improvement Plus Silver Rx (Regional PPO SNP)
|
$0.00 |
$307 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
25% | 25% | None | $86.67 |
Browse Plan Formulary |
Cigna-HealthSpring Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None | $86.11 |
Browse Plan Formulary |
Cigna-HealthSpring Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$4.00 | $12.00 | None | $85.26 |
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 |
Humana Gold Plus H4510-028 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $245.00 | None | $138.10 |
Browse Plan Formulary |
KelseyCare Advantage Rx (HMO)
|
$0.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$30.00 | n/a | None | $67.64 |
Browse Plan Formulary |
Memorial Hermann Advantage (HMO)
|
$0.00 |
$100* |
Yes, but No Gap Coverage for this drug. |
2* |
Non-Preferred Generic |
$5.00 | $10.00 | None | $101.71 |
Browse Plan Formulary |
Memorial Hermann Advantage (PPO)
|
$0.00 |
$100* |
Yes, but No Gap Coverage for this drug. |
2* |
Non-Preferred Generic |
$5.00 | $10.00 | None | $101.71 |
Browse Plan Formulary |
TexanPlus Choice (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None | $102.08 |
Browse Plan Formulary |
TexanPlus Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None | $102.08 |
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 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $112.32 |
Browse Plan Formulary |
WellCare Value (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $112.32 |
Browse Plan Formulary |
HumanaChoice R5826-091 (Regional PPO)
|
$15.00 |
$320 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $136.21 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$19.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
50% | 50% | None | $102.02 |
Browse Plan Formulary |
Care Improvement Plus Medicare Advantage (PPO)
|
$19.00 |
$315 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $86.01 |
Browse Plan Formulary |
Care Improvement Plus Medicare Advantage (Regional PPO)
|
$19.00 |
$315 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $86.67 |
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 |
WellCare Access (HMO SNP)
|
$21.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $100.00 | None | $112.30 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H4510-021 (HMO SNP)
|
$26.20 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $136.65 |
Browse Plan Formulary |
Cigna-HealthSpring TotalCare (HMO SNP)
|
$27.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $85.98 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$27.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $85.99 |
Browse Plan Formulary |
HumanaChoice R5826-012 (Regional PPO)
|
$34.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $136.21 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Choice Plus (PPO)
|
$35.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$6.00 | $33.00 | None | $102.03 |
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 |
Advantra (PPO)
|
$41.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $101.98 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Choice Premier (PPO)
|
$55.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$6.00 | $33.00 | None | $102.03 |
Browse Plan Formulary |
HumanaChoice H6609-108 (PPO)
|
$66.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $136.45 |
Browse Plan Formulary |
KelseyCare Advantage Rx+Choice (HMO-POS)
|
$77.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$30.00 | n/a | None | $67.64 |
Browse Plan Formulary |
Humana Gold Choice H8145-084 (PFFS)
|
$89.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $136.80 |
Browse Plan Formulary |
Aetna Medicare Value Plan (PPO)
|
$92.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
50% | 50% | None | $102.02 |
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 |
Aetna Medicare Select Plus Plan (PPO)
|
$139.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $112.50 | None | $101.85 |
Browse Plan Formulary |
KelseyCare Advantage Rx Premier (HMO)
|
$221.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$20.00 | n/a | None | $67.64 |
Browse Plan Formulary |