SULFAMETHOXAZOLE-TRIMETHOPRIM TABLET 400-80MG (500 CT) (500 BOT) (NDC: 00603578028)
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 SecureHorizons (HMO)
|
$0.00 |
$165* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$8.00 | $16.00 | None | $17.30 |
Browse Plan Formulary |
Amerigroup Medicare-Medicaid Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | 0% | None | $18.84 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$4.00 | $8.00 | None | $18.53 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$4.00 | $8.00 | None | $18.89 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$4.00 | $8.00 | None | $20.57 |
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 |
1 |
Preferred Generic |
$4.00 | $8.00 | None | $21.71 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$4.00 | $8.00 | None | $18.08 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$4.00 | $8.00 | None | $21.44 |
Browse Plan Formulary |
Amerivantage Specialty + Rx (HMO SNP)
|
$0.00 |
$320* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $19.06 |
Browse Plan Formulary |
Care Improvement Plus Dual Advantage (Regional PPO SNP)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $17.16 |
Browse Plan Formulary |
Care Improvement Plus Gold Rx (PPO SNP)
|
$0.00 |
$315* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$12.00 | $24.00 | None | $17.19 |
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 Gold Rx (Regional PPO SNP)
|
$0.00 |
$315* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$10.00 | $20.00 | None | $17.16 |
Browse Plan Formulary |
Care Improvement Plus Silver Rx (Regional PPO SNP)
|
$0.00 |
$307 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
25% | 25% | None | $17.16 |
Browse Plan Formulary |
Care N' Care Health Plan I (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $11.84 |
Browse Plan Formulary |
Care N' Care Health Plan III (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$4.00 | $10.00 | None | $10.64 |
Browse Plan Formulary |
Cigna-HealthSpring CarePlan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | 0% | None | $13.49 |
Browse Plan Formulary |
Humana Gold Plus H4510-018 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$2.00 | $0.00 | None | $6.59 |
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 |
TexanPlus Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$2.00 | $2.00 | None | $11.62 |
Browse Plan Formulary |
Vital Traditions (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$2.00 | $4.00 | None | $10.12 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $23.62 |
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 | $23.62 |
Browse Plan Formulary |
HumanaChoice R5826-091 (Regional PPO)
|
$15.00 |
$320* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$6.00 | $0.00 | None | $6.59 |
Browse Plan Formulary |
Care Improvement Plus Medicare Advantage (PPO)
|
$19.00 |
$315* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$12.00 | $24.00 | None | $17.19 |
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 Medicare Advantage (Regional PPO)
|
$19.00 |
$315* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$12.00 | $24.00 | None | $17.16 |
Browse Plan Formulary |
Cigna-HealthSpring TotalCare (HMO SNP)
|
$20.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $11.59 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$20.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $17.30 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$21.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$2.00 | $5.00 | None | $23.66 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H4510-021 (HMO SNP)
|
$26.20 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $6.59 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$27.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $17.30 |
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 |
Cigna-HealthSpring Preferred (HMO)
|
$28.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$3.00 | $9.00 | None | $11.69 |
Browse Plan Formulary |
Cigna-HealthSpring Preferred (PPO)
|
$30.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $11.48 |
Browse Plan Formulary |
HumanaChoice R5826-012 (Regional PPO)
|
$34.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$7.00 | $0.00 | None | $6.59 |
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 | $6.51 |
Browse Plan Formulary |
Care N' Care Health Plan II (PPO)
|
$36.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $10.64 |
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 | $6.51 |
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 |
HumanaChoice H6609-108 (PPO)
|
$66.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$7.00 | $0.00 | None | $6.59 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$68.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | None | $18.01 |
Browse Plan Formulary |
Care N' Care Health Plan I (PPO)
|
$82.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $10.64 |
Browse Plan Formulary |
Humana Gold Choice H8145-084 (PFFS)
|
$89.00 |
$200* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$6.00 | $0.00 | None | $6.59 |
Browse Plan Formulary |