KOMBIGLYZE XR 2.5-1,000 MG TAB (60 EA ) (NDC: 00310612560)
2018 Medicare Prescription Drug Plan (MAPD) Information
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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 |
BCN Advantage HMO HealthyValue (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $200.72 |
Browse Plan Formulary |
BCN Advantage HMO HealthyValue (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $199.33 |
Browse Plan Formulary |
BCN Advantage HMO HealthyValue (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $197.39 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $198.70 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $197.19 |
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 |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $200.08 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $196.87 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $199.10 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | S Q:60 /30Days | $205.21 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | S Q:60 /30Days | $201.12 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | S Q:60 /30Days | $201.18 |
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 |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | S Q:60 /30Days | $202.39 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | S Q:60 /30Days | $202.47 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | S Q:60 /30Days | $202.39 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | S Q:60 /30Days | $202.47 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | S Q:60 /30Days | $205.21 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | S Q:60 /30Days | $201.12 |
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 |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | S Q:60 /30Days | $201.18 |
Browse Plan Formulary |
HumanaChoice R3887-002 (Regional PPO)
|
$20.00 |
$405 |
to be determined |
4 |
Non-Preferred Drug |
25% | 25% | Q:60 /30Days | $204.08 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$23.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $199.33 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$23.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $197.39 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$23.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $200.72 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$29.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $197.47 |
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 |
Medicare Plus Blue PPO Essential (PPO)
|
$29.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $199.67 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$29.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $196.87 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$29.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $199.65 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$29.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $199.10 |
Browse Plan Formulary |
BCN Advantage HMO ConnectedCare (HMO)
|
$56.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $197.39 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$63.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | S Q:60 /30Days | $205.21 |
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 |
PriorityMedicare Merit (PPO)
|
$85.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | S Q:60 /30Days | $202.47 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$85.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | S Q:60 /30Days | $205.21 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$85.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | S Q:60 /30Days | $201.12 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$85.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | S Q:60 /30Days | $201.18 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$85.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | S Q:60 /30Days | $202.39 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$104.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $199.65 |
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 |
Medicare Plus Blue PPO Vitality (PPO)
|
$104.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $199.10 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$104.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $197.47 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$104.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $199.67 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$104.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $196.87 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$152.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:180 /90Days | $200.08 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$152.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:180 /90Days | $196.87 |
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 |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$152.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:180 /90Days | $199.10 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$152.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:180 /90Days | $198.70 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$152.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:180 /90Days | $197.19 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$155.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | n/a | S Q:60 /30Days | $205.21 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$179.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | n/a | S Q:60 /30Days | $201.18 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$179.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | n/a | S Q:60 /30Days | $202.39 |
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 |
PriorityMedicare Select (PPO)
|
$179.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | n/a | S Q:60 /30Days | $202.47 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$179.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | n/a | S Q:60 /30Days | $205.21 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$179.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | n/a | S Q:60 /30Days | $201.12 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$179.50 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $196.87 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$179.50 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $199.67 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$179.50 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $199.65 |
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 |
Medicare Plus Blue PPO Signature (PPO)
|
$179.50 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $199.10 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$179.50 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /90Days | $197.47 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$301.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:180 /90Days | $199.10 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$301.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:180 /90Days | $198.70 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$301.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:180 /90Days | $197.19 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$301.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:180 /90Days | $200.08 |
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 |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$301.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:180 /90Days | $196.87 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$312.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:180 /90Days | $199.10 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$312.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:180 /90Days | $197.47 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$312.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:180 /90Days | $199.67 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$312.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:180 /90Days | $196.87 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$312.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:180 /90Days | $199.65 |
Browse Plan Formulary |