COMBIVENT RESPIMAT INHAL SPRAY (4 GM ) (NDC: 00597002402)
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 |
$220 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $125.00 | None | $298.43 |
Browse Plan Formulary |
AARP MedicareComplete Choice Plan 2 (Regional PPO)
|
$0.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $125.00 | None | $298.26 |
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 | Q:8 /30Days | $300.39 |
Browse Plan Formulary |
Amerivantage Specialty + Rx (HMO SNP)
|
$0.00 |
$320 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$70.00 | $210.00 | Q:8 /30Days | $300.39 |
Browse Plan Formulary |
BlueMedicare HMO LifeTime (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:8 /30Days | $302.61 |
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 MyTime (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$80.00 | $240.00 | Q:8 /30Days | $302.51 |
Browse Plan Formulary |
CareDirect (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$85.00 | $245.00 | Q:4 /20Days | $299.51 |
Browse Plan Formulary |
CareFree (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$60.00 | $170.00 | Q:4 /20Days | $299.51 |
Browse Plan Formulary |
CareOne (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$85.00 | $245.00 | Q:4 /20Days | $299.51 |
Browse Plan Formulary |
CareOne PLUS (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$60.00 | $170.00 | Q:4 /20Days | $299.51 |
Browse Plan Formulary |
Coventry Summit Ideal (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Preferred Brand |
$25.00 | $50.00 | Q:8 /30Days | $302.82 |
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 Summit Plus (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$35.00 | $70.00 | Q:8 /30Days | $303.03 |
Browse Plan Formulary |
Freedom Platinum Plan Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Non-Preferred Brand |
$80.00 | $160.00 | Q:30 /30Days | $296.82 |
Browse Plan Formulary |
Freedom VIP Care (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Non-Preferred Brand |
$75.00 | $150.00 | Q:30 /30Days | $296.69 |
Browse Plan Formulary |
Freedom VIP Savings (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Non-Preferred Brand |
$80.00 | $160.00 | Q:30 /30Days | $296.69 |
Browse Plan Formulary |
Freedom VIP Savings COPD (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Non-Preferred Brand |
$80.00 | $160.00 | Q:30 /30Days | $296.69 |
Browse Plan Formulary |
Humana Gold Plus H1036-230 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:4 /20Days | $299.60 |
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 |
HumanaChoice R5826-074 (Regional PPO)
|
$0.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:4 /20Days | $299.55 |
Browse Plan Formulary |
Optimum Diamond Rewards (HMO-POS SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Non-Preferred Brand |
$80.00 | $160.00 | Q:30 /30Days | $296.96 |
Browse Plan Formulary |
Optimum Diamond Rewards COPD (HMO-POS SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Tier 3 |
$80.00 | $160.00 | Q:30 /30Days | $296.92 |
Browse Plan Formulary |
Optimum Platinum Plan (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Non-Preferred Brand |
$80.00 | $160.00 | Q:30 /30Days | $297.04 |
Browse Plan Formulary |
Preferred Secure Option (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$45.00 | $125.00 | None | $298.52 |
Browse Plan Formulary |
Simply Extra (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | n/a | Q:8 /30Days | $297.98 |
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. | 4 |
Non-Preferred Brand |
$55.00 | n/a | Q:8 /30Days | $297.98 |
Browse Plan Formulary |
Simply More (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$55.00 | n/a | Q:8 /30Days | $297.98 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$35.00 | $87.50 | Q:8 /20Days | $308.09 |
Browse Plan Formulary |
WellCare Essential (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$35.00 | $87.50 | Q:8 /20Days | $308.14 |
Browse Plan Formulary |
WellCare Value (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$25.00 | $62.50 | Q:8 /20Days | $308.03 |
Browse Plan Formulary |
Coventry Summit Maximum (HMO SNP)
|
$9.70 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$45.00 | $90.00 | Q:8 /30Days | $302.79 |
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 H1036-231 (HMO SNP)
|
$17.40 |
$285 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:4 /20Days | $299.60 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$17.70 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $100.00 | Q:8 /20Days | $308.33 |
Browse Plan Formulary |
CareNeeds (HMO SNP)
|
$17.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:4 /20Days | $299.51 |
Browse Plan Formulary |
WellCare Liberty (HMO SNP)
|
$18.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $100.00 | Q:8 /20Days | $308.33 |
Browse Plan Formulary |
WellCare Select (HMO SNP)
|
$19.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $100.00 | Q:8 /20Days | $308.27 |
Browse Plan Formulary |
BlueMedicare Regional PPO (Regional PPO)
|
$20.20 |
$100 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:8 /30Days | $302.55 |
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 |
UnitedHealthcare Dual Complete LP (HMO SNP)
|
$24.30 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | None | $298.43 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$24.30 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $298.37 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$24.80 |
$320 | Yes, but No Gap Coverage for this drug. | 3 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:8 /30Days | $300.82 |
Browse Plan Formulary |
Freedom Medi-Medi Full (HMO SNP)
|
$25.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:30 /30Days | $296.70 |
Browse Plan Formulary |
Freedom Medi-Medi Partial (HMO SNP)
|
$25.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | Q:30 /30Days | $296.70 |
Browse Plan Formulary |
Optimum Emerald Full (HMO SNP)
|
$25.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:30 /30Days | $296.73 |
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 |
Optimum Emerald Partial (HMO SNP)
|
$25.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:30 /30Days | $296.73 |
Browse Plan Formulary |
Simply Complete (HMO SNP)
|
$25.80 |
$320 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$90.00 | n/a | Q:8 /30Days | $297.98 |
Browse Plan Formulary |
Sunshine Health Advantage (HMO SNP)
|
$25.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$45.00 | $45.00 | Q:8 /30Days | $307.82 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP (Regional PPO SNP)
|
$25.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | None | $298.26 |
Browse Plan Formulary |
HumanaChoice R5826-005 (Regional PPO)
|
$39.40 |
$100 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$85.00 | $245.00 | Q:4 /20Days | $299.55 |
Browse Plan Formulary |
Humana Gold Choice H8145-061 (PFFS)
|
$101.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:4 /20Days | $299.56 |
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 |
BlueMedicare PPO (PPO)
|
$127.10 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$75.00 | $225.00 | Q:8 /30Days | $302.61 |
Browse Plan Formulary |