IPRATROPIUM BROMIDE and ALBUTEROL SULFATE 2.5; 0.5mg/3mL; mg/3mL 6 POUCH per CARTON / 5 VIAL, PLAS (6 POUCH in 1 CARTON / 5 V ) (NDC: 00093672373)
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 |
Advantra Silver (HMO)
![Email Prescription and/or Health Benefit details for Advantra Silver (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$12.00 | $30.00 | P | $12.26 |
Browse Plan Formulary |
Advantra Silver (PPO)
![Email Prescription and/or Health Benefit details for Advantra Silver (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$13.00 | $39.00 | P | $12.30 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Classic Complete Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$20.00 | $60.00 | P | $10.27 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Classic Complete Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$20.00 | $60.00 | P | $14.76 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Classic Complete Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$20.00 | $60.00 | P | $10.27 |
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 |
Geisinger Gold Classic Complete Rx (HMO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Classic Complete Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$20.00 | $60.00 | P | $10.27 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Classic Complete Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$20.00 | $60.00 | P | $17.53 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Preferred Complete Rx (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$20.00 | $60.00 | P | $17.53 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Preferred Complete Rx (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$20.00 | $60.00 | P | $10.27 |
Browse Plan Formulary |
Humana Gold Plus H6859-001 (HMO)
![Email Prescription and/or Health Benefit details for Humana Gold Plus H6859-001 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$200* |
Yes, but No Gap Coverage for this drug. |
2* |
Non-Preferred Generic |
$18.00 | $0.00 | P | $8.39 |
Browse Plan Formulary |
UPMC for Life HMO Deductible with Rx (HMO)
![Email Prescription and/or Health Benefit details for UPMC for Life HMO Deductible with Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$10.00 | $20.00 | P | $9.26 |
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 |
Cigna-HealthSpring TotalCare (HMO SNP)
![Email Prescription and/or Health Benefit details for Cigna-HealthSpring TotalCare (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$25.40 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P Q:540 /30Days | $7.09 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Nursing Home Plan (PPO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$27.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | P | $7.27 |
Browse Plan Formulary |
Cigna-HealthSpring Achieve (HMO SNP)
![Email Prescription and/or Health Benefit details for Cigna-HealthSpring Achieve (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$28.50 |
$280* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | P Q:540 /30Days | $7.19 |
Browse Plan Formulary |
AdvantraOne (PPO)
![Email Prescription and/or Health Benefit details for AdvantraOne (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | P | $12.27 |
Browse Plan Formulary |
Cigna-HealthSpring Preferred (HMO)
![Email Prescription and/or Health Benefit details for Cigna-HealthSpring Preferred (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.50 |
$280* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | P Q:540 /30Days | $7.07 |
Browse Plan Formulary |
Cigna-HealthSpring Preferred (HMO)
![Email Prescription and/or Health Benefit details for Cigna-HealthSpring Preferred (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.50 |
$280* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$10.00 | $30.00 | P Q:540 /30Days | $7.61 |
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 |
Advantra Cares (HMO SNP)
![Email Prescription and/or Health Benefit details for Advantra Cares (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$33.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | P | $11.56 |
Browse Plan Formulary |
AmeriHealth VIP Care (HMO SNP)
![Email Prescription and/or Health Benefit details for AmeriHealth VIP Care (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$33.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $8.25 |
Browse Plan Formulary |
Gateway Health Medicare Assured Diamond (HMO SNP)
![Email Prescription and/or Health Benefit details for Gateway Health Medicare Assured Diamond (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$33.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | n/a | P | $10.62 |
Browse Plan Formulary |
Gateway Health Medicare Assured Ruby (HMO SNP)
![Email Prescription and/or Health Benefit details for Gateway Health Medicare Assured Ruby (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$33.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | P | $10.62 |
Browse Plan Formulary |
Geisinger Gold Secure Rx (HMO SNP)
![Email Prescription and/or Health Benefit details for Geisinger Gold Secure Rx (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$33.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P | $13.00 |
Browse Plan Formulary |
HumanaChoice H5525-006 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice H5525-006 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$34.00 |
$320* |
Yes, but No Gap Coverage for this drug. |
2* |
Non-Preferred Generic |
$18.00 | $0.00 | P | $8.39 |
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 |
UPMC for Life PPO High Deductible with Rx (PPO)
![Email Prescription and/or Health Benefit details for UPMC for Life PPO High Deductible with Rx (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$10.00 | $20.00 | P | $9.26 |
Browse Plan Formulary |
HumanaChoice R5826-002 (Regional PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice R5826-002 (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$39.90 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$18.00 | $0.00 | P | $8.39 |
Browse Plan Formulary |
Gateway Health Medicare Assured Gold (HMO SNP)
![Email Prescription and/or Health Benefit details for Gateway Health Medicare Assured Gold (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$46.30 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | P | $10.62 |
Browse Plan Formulary |
Advantra Silver Plus (HMO)
![Email Prescription and/or Health Benefit details for Advantra Silver Plus (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$22.00 | $66.00 | P | $12.30 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (HMO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Standard Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | P | $16.18 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (PPO)
![Email Prescription and/or Health Benefit details for UnitedHealthcare MedicareComplete Choice (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$49.00 |
$230* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$2.00 | $4.00 | P | $6.21 |
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 H8145-052 (PFFS)
![Email Prescription and/or Health Benefit details for Humana Gold Choice H8145-052 (PFFS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$62.00 |
$320* |
Yes, but No Gap Coverage for this drug. |
2* |
Non-Preferred Generic |
$18.00 | $0.00 | P | $8.39 |
Browse Plan Formulary |
Advantra Silver Plus (PPO)
![Email Prescription and/or Health Benefit details for Advantra Silver Plus (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$67.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$9.00 | $27.00 | P | $12.29 |
Browse Plan Formulary |
Freedom Blue PPO HD Rx (PPO)
![Email Prescription and/or Health Benefit details for Freedom Blue PPO HD Rx (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$70.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$12.00 | $30.00 | P | $14.65 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Preferred Advantage Rx (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$70.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | P | $17.53 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Preferred Advantage Rx (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$70.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | P | $10.27 |
Browse Plan Formulary |
SeniorBlue - Option 2 (PPO)
![Email Prescription and/or Health Benefit details for SeniorBlue - Option 2 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$72.40 |
$0 |
to be determined |
2 |
Tier 2 |
$17.00 | $51.00 | P | $12.06 |
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 |
Gateway Health Medicare Assured Platinum (HMO SNP)
![Email Prescription and/or Health Benefit details for Gateway Health Medicare Assured Platinum (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$77.80 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | P | $10.62 |
Browse Plan Formulary |
Freedom Blue PPO ValueRx (PPO)
![Email Prescription and/or Health Benefit details for Freedom Blue PPO ValueRx (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$12.00 | $30.00 | P | $14.65 |
Browse Plan Formulary |
Advantra Gold (PPO)
![Email Prescription and/or Health Benefit details for Advantra Gold (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$116.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | P | $12.30 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Premier Plan (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$124.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $45.00 | P | $16.53 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Classic Advantage Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | P | $17.53 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Classic Advantage Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | P | $10.27 |
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 |
Geisinger Gold Classic Advantage Rx (HMO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Classic Advantage Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | P | $14.76 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Classic Advantage Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | P | $10.27 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Classic Advantage Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | P | $10.27 |
Browse Plan Formulary |
Aetna Medicare Select Plus Plan (PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Select Plus Plan (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$139.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$3.00 | $7.50 | P | $18.55 |
Browse Plan Formulary |
SeniorBlue - Option 1 (PPO)
![Email Prescription and/or Health Benefit details for SeniorBlue - Option 1 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$191.90 |
$0 |
to be determined |
2 |
Tier 2 |
$10.00 | $30.00 | P | $12.06 |
Browse Plan Formulary |
Freedom Blue PPO Standard (PPO)
![Email Prescription and/or Health Benefit details for Freedom Blue PPO Standard (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$246.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$12.00 | $30.00 | P | $14.65 |
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 Blue PPO Deluxe (PPO)
![Email Prescription and/or Health Benefit details for Freedom Blue PPO Deluxe (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$296.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$12.00 | $30.00 | P | $14.65 |
Browse Plan Formulary |