VIIBRYD 20mg/1 30 FILM COATED TABLETS in BOTTLE (30 TABLET, FILM COATED in ) (NDC: 00456112030)
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 Northern Pennsylvania Gold (HMO)
![Email Prescription and/or Health Benefit details for Advantra Northern Pennsylvania Gold (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
50% | 50% | Q:30 /30Days | $194.38 |
Browse Plan Formulary |
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 |
4 |
Non-Preferred Brand |
50% | 50% | Q:30 /30Days | $195.07 |
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 |
4 |
Non-Preferred Brand |
50% | 50% | Q:30 /30Days | $195.02 |
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. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P | $190.70 |
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. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P | $189.56 |
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 |
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. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P | $190.39 |
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. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P | $189.82 |
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. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P | $190.75 |
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) |
$18.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:60 /30Days | $193.77 |
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 |
4 |
Non-Preferred Brand |
50% | 50% | Q:30 /30Days | $194.99 |
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 | Q:30 /30Days | $195.90 |
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 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 | Q:30 /30Days | $195.90 |
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 | $190.24 |
Browse Plan Formulary |
UPMC Community Care (HMO SNP)
![Email Prescription and/or Health Benefit details for UPMC Community 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 |
3 |
Tier 3 |
25% | 25% | P Q:60 /30Days | $193.35 |
Browse Plan Formulary |
UPMC for You Advantage (HMO SNP)
![Email Prescription and/or Health Benefit details for UPMC for You Advantage (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$33.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$80.00 | $240.00 | P Q:60 /30Days | $193.77 |
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. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P Q:30 /30Days | $191.25 |
Browse Plan Formulary |
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 |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:60 /30Days | $193.77 |
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 R5826-002 (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 |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P Q:30 /30Days | $191.51 |
Browse Plan Formulary |
Security Blue ValueRx (HMO)
![Email Prescription and/or Health Benefit details for Security Blue ValueRx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P | $197.44 |
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 |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days | $195.90 |
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 |
4 |
Non-Preferred Brand |
50% | 50% | Q:30 /30Days | $195.05 |
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 |
4 |
Non-Preferred Brand |
50% | 50% | Q:30 /30Days | $195.02 |
Browse Plan Formulary |
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 |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days | $195.90 |
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 HMO Rx (HMO)
![Email Prescription and/or Health Benefit details for UPMC for Life HMO Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$78.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:60 /30Days | $193.77 |
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) |
$105.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P | $197.44 |
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. |
4 |
Non-Preferred Brand |
50% | 50% | Q:30 /30Days | $195.02 |
Browse Plan Formulary |
Geisinger Gold Preferred Select Rx (PPO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Preferred Select Rx (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$119.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P | $190.75 |
Browse Plan Formulary |
Geisinger Gold Preferred Select Rx (PPO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Preferred Select Rx (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$119.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P | $190.39 |
Browse Plan Formulary |
Geisinger Gold Preferred Select Rx (PPO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Preferred Select Rx (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$119.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P | $189.82 |
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 |
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) |
$129.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P | $190.75 |
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) |
$129.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P | $189.82 |
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) |
$129.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P | $190.70 |
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) |
$129.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P | $189.56 |
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) |
$129.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P | $190.39 |
Browse Plan Formulary |
Freedom Blue PPO Select (PPO)
![Email Prescription and/or Health Benefit details for Freedom Blue PPO Select (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$137.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P | $197.44 |
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 Rx Enhanced (PPO)
![Email Prescription and/or Health Benefit details for UPMC for Life PPO Rx Enhanced (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$139.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:60 /30Days | $193.77 |
Browse Plan Formulary |
Security Blue Standard (HMO)
![Email Prescription and/or Health Benefit details for Security Blue Standard (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$201.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | P | $197.44 |
Browse Plan Formulary |
UPMC for Life HMO Rx Enhanced (HMO)
![Email Prescription and/or Health Benefit details for UPMC for Life HMO Rx Enhanced (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$223.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | P Q:60 /30Days | $193.77 |
Browse Plan Formulary |
Security Blue Deluxe (HMO)
![Email Prescription and/or Health Benefit details for Security Blue Deluxe (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$237.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | P | $197.44 |
Browse Plan Formulary |
Freedom Blue PPO Classic (PPO)
![Email Prescription and/or Health Benefit details for Freedom Blue PPO Classic (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$280.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | P | $197.44 |
Browse Plan Formulary |