ETHINYL ESTRADIOL 0.03 MG / NORGESTREL 0.3 MG ORAL TABLET/ 7 (INERT INGREDIENTS 1 MG ORAL TAB 21 (21 ) (NDC: 00555904958)
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 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 | $13.63 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
50% | 50% | None | $23.02 |
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 | None | $25.75 |
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 | None | $25.75 |
Browse Plan Formulary |
AvMed Medicare Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None | $18.78 |
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 LifeTime (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None | $18.21 |
Browse Plan Formulary |
CareDirect (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$35.00 | $95.00 | None | $20.23 |
Browse Plan Formulary |
CareFree PLUS (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$45.00 | $125.00 | None | $20.23 |
Browse Plan Formulary |
CareHeart (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$35.00 | $95.00 | None | $20.23 |
Browse Plan Formulary |
CareOne PLUS (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$35.00 | $95.00 | None | $20.23 |
Browse Plan Formulary |
Coventry Summit Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Brand |
50% | 50% | None | $21.38 |
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 Vista Ideal (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Brand |
50% | 50% | None | $21.38 |
Browse Plan Formulary |
Humana Gold Plus - Diabetes (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$35.00 | $95.00 | None | $20.23 |
Browse Plan Formulary |
Humana Gold Plus - Heart (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$35.00 | $95.00 | None | $20.23 |
Browse Plan Formulary |
Humana Gold Plus H1036-054C (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$35.00 | $95.00 | None | $20.23 |
Browse Plan Formulary |
Humana Gold Plus H1036-237 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $20.23 |
Browse Plan Formulary |
Humana Gold Plus H1036-237 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $20.23 |
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 | None | $20.23 |
Browse Plan Formulary |
Leon Medical Centers Health Plans - Leon Cares (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic |
$0.00 | n/a | None | $21.36 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Preferred Brand |
$5.00 | $5.00 | None | $8.87 |
Browse Plan Formulary |
PHP (HMO SNP)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
25% | n/a | None | $23.92 |
Browse Plan Formulary |
Preferred Choice Dade (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Preferred Brand |
$0.00 | $0.00 | None | $8.87 |
Browse Plan Formulary |
Preferred Complete Care (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Preferred Brand |
$0.00 | $0.00 | None | $8.87 |
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 |
Preferred Special Care Miami-Dade (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Preferred Brand |
$0.00 | $0.00 | None | $8.87 |
Browse Plan Formulary |
Simply Extra (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $22.18 |
Browse Plan Formulary |
Simply Level (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $22.18 |
Browse Plan Formulary |
Simply More (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $22.18 |
Browse Plan Formulary |
WellCare Dividend (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $27.04 |
Browse Plan Formulary |
WellCare Essential (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $24.82 |
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 |
CareNeeds (HMO SNP)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $20.23 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-077A (HMO SNP)
|
$15.10 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $20.23 |
Browse Plan Formulary |
WellCare Select (HMO SNP)
|
$19.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$11.00 | $27.50 | None | $24.97 |
Browse Plan Formulary |
BlueMedicare Regional PPO (Regional PPO)
|
$20.20 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$28.00 | $84.00 | None | $18.19 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$20.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$24.00 | $60.00 | None | $27.04 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax Plus (HMO-POS SNP)
|
$24.30 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Preferred Brand |
25% | 25% | None | $12.70 |
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 |
Preferred Medicare Assist (HMO-POS SNP)
|
$24.40 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Preferred Brand |
$0.00 | $0.00 | None | $12.70 |
Browse Plan Formulary |
Coventry Summit Maximum (HMO SNP)
|
$24.60 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Brand |
50% | 50% | None | $19.89 |
Browse Plan Formulary |
WellCare Liberty (HMO SNP)
|
$24.60 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$33.00 | $82.50 | None | $27.04 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$24.80 |
$320* |
Yes, but No Gap Coverage for this drug. |
1* |
Generic |
$0.00 | $0.00 | None | $20.93 |
Browse Plan Formulary |
Coventry Vista Maximum (HMO SNP)
|
$25.80 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
50% | 50% | None | $20.76 |
Browse Plan Formulary |
Simply Care (HMO SNP)
|
$25.80 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$5.00 | n/a | None | $22.18 |
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 Comfort (HMO SNP)
|
$25.80 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$5.00 | n/a | None | $22.18 |
Browse Plan Formulary |
Simply Complete (HMO SNP)
|
$25.80 |
$320* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $22.18 |
Browse Plan Formulary |
Sunshine Health Advantage (HMO SNP)
|
$25.80 |
$320* |
Yes, but No Gap Coverage for this drug. |
1* |
Generic |
$0.00 | $0.00 | None | $23.83 |
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 | $13.63 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$31.60 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | None | $11.07 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$35.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
50% | 50% | None | $23.44 |
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 |
HumanaChoice R5826-005 (Regional PPO)
|
$39.40 |
$100 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $245.00 | None | $20.23 |
Browse Plan Formulary |
HumanaChoice H5415-056 (PPO)
|
$43.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $245.00 | None | $20.23 |
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 | None | $20.23 |
Browse Plan Formulary |
Aetna Medicare Select Plus Plan (HMO)
|
$139.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
50% | 50% | None | $23.47 |
Browse Plan Formulary |
Aetna Medicare Select Plus Plan (PPO)
|
$139.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
50% | 50% | None | $23.57 |
Browse Plan Formulary |