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 |
AARP MedicareComplete SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $219.44 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $219.44 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $219.44 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $219.44 |
Browse Plan Formulary |
Alignment Health Plan Heart & Diabetes (HMO SNP)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$30.00 | n/a | Q:60 /30Days | $206.08 |
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 |
Alignment Health Plan Heart & Diabetes (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | n/a | Q:60 /30Days | $206.08 |
Browse Plan Formulary |
Alignment Health Plan My Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | n/a | Q:60 /30Days | $206.00 |
Browse Plan Formulary |
Alignment Health Plan My Choice (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$30.00 | n/a | Q:60 /30Days | $206.00 |
Browse Plan Formulary |
Alignment Health Plan Platinum (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$30.00 | n/a | Q:60 /30Days | $206.08 |
Browse Plan Formulary |
Alignment Health Plan Platinum (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | n/a | Q:60 /30Days | $206.08 |
Browse Plan Formulary |
Alignment Health Plan smartHMO (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | n/a | Q:60 /30Days | $206.08 |
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 |
Alignment Health Plan smartHMO (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$30.00 | n/a | Q:60 /30Days | $206.08 |
Browse Plan Formulary |
Golden State Medicare Gold (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | S Q:60 /30Days | $203.48 |
Browse Plan Formulary |
Golden State Medicare Gold (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | S Q:60 /30Days | $203.38 |
Browse Plan Formulary |
Golden State Medicare Gold (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | S Q:60 /30Days | $202.97 |
Browse Plan Formulary |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | P | $202.28 |
Browse Plan Formulary |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | P | $202.28 |
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 Gold Select (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P | $207.96 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P | $208.03 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P | $207.96 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P | $208.03 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P | $207.96 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P | $208.03 |
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 (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P | $208.02 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P | $208.02 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:60 /30Days | $204.09 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:60 /30Days | $204.09 |
Browse Plan Formulary |
Inter Valley Health Plan Service To Seniors (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | n/a | Q:60 /30Days | $209.68 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | n/a | None | $213.55 |
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 |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | n/a | None | $213.55 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$30.00 | n/a | None | $202.74 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | n/a | None | $202.74 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$42.00 | n/a | None | $202.80 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | n/a | None | $202.80 |
Browse Plan Formulary |
SCAN Classic II (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$42.00 | n/a | None | $202.80 |
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 |
SCAN Connections (HMO SNP)
|
$0.00 |
$405 |
to be determined |
3 |
Preferred Brand |
25% | n/a | None | $202.71 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
|
$0.00 |
$405 |
to be determined |
3 |
Preferred Brand |
25% | n/a | None | $202.80 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$42.00 | n/a | None | $202.67 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | n/a | None | $202.67 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | n/a | None | $213.97 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$12.70 |
$0 |
to be determined |
4 |
Tier 4 |
$100.00 | n/a | None | $213.97 |
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 |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$12.70 |
$0 |
to be determined |
4 |
Tier 4 |
$100.00 | n/a | None | $213.97 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$16.30 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $204.09 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$16.30 |
$405 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $204.09 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$17.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P | $207.96 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$17.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P | $208.03 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 3 (HMO)
|
$17.30 |
$405 |
to be determined |
3 |
Tier 3 |
25% | n/a | Q:60 /30Days | $219.51 |
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 |
AARP MedicareComplete SecureHorizons Plan 3 (HMO)
|
$17.30 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | n/a | Q:60 /30Days | $219.51 |
Browse Plan Formulary |
SCAN Classic II (HMO)
|
$24.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | n/a | None | $202.80 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Premier (HMO)
|
$26.70 |
$0 |
to be determined |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $219.44 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Premier (HMO)
|
$26.70 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $219.44 |
Browse Plan Formulary |
SCAN Connections (HMO SNP)
|
$30.00 |
$405 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
25% | n/a | None | $202.71 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$32.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | n/a | None | $213.97 |
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 |
SCAN Connections at Home (HMO SNP)
|
$35.20 |
$405 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
25% | n/a | None | $202.80 |
Browse Plan Formulary |
Alignment Health Plan CalPlus (HMO)
|
$35.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | n/a | Q:60 /30Days | $206.07 |
Browse Plan Formulary |
Alignment Health Plan CalPlus (HMO)
|
$35.50 |
$405 |
to be determined |
3 |
Preferred Brand |
$40.00 | n/a | Q:60 /30Days | $206.07 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$35.50 |
$140 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $202.37 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$35.50 |
$140 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $202.37 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$35.50 |
$190 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $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 |
Health Net Seniority Plus Amber II (HMO SNP)
|
$35.50 |
$190 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $202.27 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$35.50 |
$190 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $202.25 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$35.50 |
$190 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $202.27 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$35.50 |
$190 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $202.39 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$35.50 |
$190 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $202.25 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$35.50 |
$240 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $202.25 |
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 Seniority Plus Sapphire (HMO)
|
$35.50 |
$240 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $202.27 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$35.50 |
$240 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $202.27 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$35.50 |
$240 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $202.25 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$35.50 |
$240 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $202.27 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$35.50 |
$240 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $202.27 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$35.50 |
$85 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $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 |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$35.50 |
$85 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $202.39 |
Browse Plan Formulary |
Inter Valley Health Plan Value Preferred Choice (HMO)
|
$35.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | Q:60 /30Days | $209.61 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$35.50 |
$405 |
to be determined |
3 |
Preferred Brand |
25% | n/a | None | $202.69 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$35.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | n/a | None | $202.69 |
Browse Plan Formulary |
VillageHealth (HMO-POS SNP)
|
$35.50 |
$405 |
to be determined |
3 |
Preferred Brand |
25% | n/a | None | $202.74 |
Browse Plan Formulary |
VillageHealth (HMO-POS SNP)
|
$35.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | n/a | None | $202.74 |
Browse Plan Formulary |