VIGABATRIN 50 MG/ML ORAL SOLUTION [SABRIL] (NDC: 67386021165)
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 |
$205* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | 33% | P Q:180 /30Days | $4,556.48 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
50% | 50% | P | $4,724.59 |
Browse Plan Formulary |
Blue Medicare Advantage Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Tier 5 |
33% | n/a | None | $4,570.87 |
Browse Plan Formulary |
CareMore Breathe (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $212.50 | Q:180 /30Days | $4,634.11 |
Browse Plan Formulary |
CareMore Diabetes (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $212.50 | Q:180 /30Days | $4,634.11 |
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 |
CareMore Heart (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $212.50 | Q:180 /30Days | $4,634.11 |
Browse Plan Formulary |
CareMore StartSmart Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:180 /30Days | $4,634.11 |
Browse Plan Formulary |
CareMore Value Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $212.50 | Q:180 /30Days | $4,634.11 |
Browse Plan Formulary |
Cigna-HealthSpring Achieve Plus (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | Q:200 /30Days | $4,392.60 |
Browse Plan Formulary |
Cigna-HealthSpring Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | Q:200 /30Days | $4,392.60 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | None | $4,738.48 |
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 |
Health Net Jade Cardiovascular (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | None | $4,738.48 |
Browse Plan Formulary |
Health Net Ruby Select (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | None | $4,730.82 |
Browse Plan Formulary |
Humana Gold Plus - Diabetes and Heart (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:180 /30Days | $4,558.26 |
Browse Plan Formulary |
Humana Gold Plus H2649-032 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:180 /30Days | $4,558.26 |
Browse Plan Formulary |
Phoenix Advantage (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:180 /30Days | $4,723.33 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,579.00 |
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 |
Blue Medicare Advantage Plus (HMO)
|
$23.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Tier 5 |
33% | n/a | None | $4,570.87 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$29.60 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | P Q:180 /30Days | $4,556.48 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$30.20 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:180 /30Days | $4,556.48 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete ONE (HMO SNP)
|
$31.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | P Q:180 /30Days | $4,556.48 |
Browse Plan Formulary |
Bridgeway Health Solutions Advantage (HMO SNP)
|
$32.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | Q:360 /30Days | $4,537.60 |
Browse Plan Formulary |
Care1st+ (HMO SNP)
|
$32.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $4,618.17 |
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 |
Health Net Amber (HMO SNP)
|
$32.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | None | $4,730.82 |
Browse Plan Formulary |
Mercy Care Advantage (HMO SNP)
|
$32.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P Q:180 /30Days | $4,823.13 |
Browse Plan Formulary |
Mercy Care Advantage (HMO SNP)
|
$32.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P Q:180 /30Days | $4,823.13 |
Browse Plan Formulary |
Mercy Care Advantage (HMO SNP)
|
$32.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P Q:180 /30Days | $4,823.13 |
Browse Plan Formulary |
Mercy Maricopa Advantage (HMO SNP)
|
$32.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P Q:180 /30Days | $4,823.13 |
Browse Plan Formulary |
Health Choice Generations (HMO SNP)
|
$32.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $4,544.46 |
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 |
Maricopa Care Advantage (HMO SNP)
|
$32.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $4,602.24 |
Browse Plan Formulary |
Phoenix Advantage Plus (HMO SNP)
|
$32.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P Q:180 /30Days | $4,723.33 |
Browse Plan Formulary |
Phoenix Advantage Select (HMO)
|
$39.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:180 /30Days | $4,723.33 |
Browse Plan Formulary |
HumanaChoice R5826-014 (Regional PPO)
|
$41.00 |
$190 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | P Q:180 /30Days | $4,558.26 |
Browse Plan Formulary |
Health Net Ruby 1 (HMO)
|
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | None | $4,738.48 |
Browse Plan Formulary |
Health Net Ruby 1 (HMO)
|
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | None | $4,738.48 |
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 Plus (HMO)
|
$50.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | Q:200 /30Days | $4,392.60 |
Browse Plan Formulary |
Blue Medicare Advantage Premier (HMO)
|
$62.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $4,570.87 |
Browse Plan Formulary |
Humana Gold Plus H2649-030 (HMO-POS)
|
$77.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:180 /30Days | $4,558.26 |
Browse Plan Formulary |
HumanaChoice H6609-133 (PPO)
|
$120.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:180 /30Days | $4,558.26 |
Browse Plan Formulary |
Humana Gold Choice H8145-103 (PFFS)
|
$178.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:180 /30Days | $4,558.26 |
Browse Plan Formulary |