KOMBIGLYZE XR 5-500 MG TABLET (30 EA ) (NDC: 00310613530)
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-POS Basic (HMO-POS)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:90 /90Days | $403.28 |
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:90 /90Days | $393.78 |
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:90 /90Days | $405.24 |
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:90 /90Days | $396.41 |
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:90 /90Days | $387.35 |
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:30 /30Days | $405.42 |
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:30 /30Days | $403.37 |
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:30 /30Days | $395.38 |
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:30 /30Days | $395.38 |
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:30 /30Days | $417.73 |
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:30 /30Days | $417.73 |
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:30 /30Days | $405.42 |
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:30 /30Days | $403.37 |
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:30 /30Days | $395.38 |
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:30 /30Days | $395.38 |
Browse Plan Formulary |
HumanaChoice R3887-002 (Regional PPO)
|
$20.00 |
$405 |
to be determined |
4 |
Non-Preferred Drug |
25% | 25% | Q:30 /30Days | $407.12 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$24.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:90 /90Days | $393.78 |
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 |
Medicare Plus Blue PPO Essential (PPO)
|
$24.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:90 /90Days | $405.24 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$24.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:90 /90Days | $396.41 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$24.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:90 /90Days | $391.01 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$24.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:90 /90Days | $403.28 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$72.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | S Q:30 /30Days | $395.38 |
Browse Plan Formulary |
HumanaChoice H5216-009 (PPO)
|
$75.00 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $407.13 |
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)
|
$82.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | S Q:30 /30Days | $405.42 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$82.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | S Q:30 /30Days | $403.37 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$82.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | S Q:30 /30Days | $395.38 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$82.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | S Q:30 /30Days | $395.38 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$82.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | S Q:30 /30Days | $417.73 |
Browse Plan Formulary |
Paramount Elite - Enhanced Medical and Drug (HMO)
|
$85.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | n/a | Q:30 /30Days | $403.71 |
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)
|
$86.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:90 /90Days | $391.01 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$86.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:90 /90Days | $403.28 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$86.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:90 /90Days | $393.78 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$86.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:90 /90Days | $405.24 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$86.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:90 /90Days | $396.41 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$145.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:90 /90Days | $405.24 |
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)
|
$145.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:90 /90Days | $396.41 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$145.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:90 /90Days | $387.35 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$145.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:90 /90Days | $403.28 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$145.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:90 /90Days | $393.78 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$160.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | n/a | S Q:30 /30Days | $395.38 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$171.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | n/a | S Q:30 /30Days | $395.38 |
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 |
PriorityMedicare Select (PPO)
|
$171.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | n/a | S Q:30 /30Days | $417.73 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$171.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | n/a | S Q:30 /30Days | $405.42 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$171.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | n/a | S Q:30 /30Days | $403.37 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$171.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | n/a | S Q:30 /30Days | $395.38 |
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:90 /90Days | $405.24 |
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:90 /90Days | $396.41 |
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:90 /90Days | $391.01 |
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:90 /90Days | $403.28 |
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:90 /90Days | $393.78 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$269.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:90 /90Days | $403.28 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$269.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:90 /90Days | $393.78 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$269.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:90 /90Days | $405.24 |
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 Assure (PPO)
|
$269.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:90 /90Days | $396.41 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$269.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:90 /90Days | $391.01 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$306.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:90 /90Days | $387.35 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$306.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:90 /90Days | $403.28 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$306.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:90 /90Days | $393.78 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$306.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:90 /90Days | $405.24 |
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)
|
$306.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:90 /90Days | $396.41 |
Browse Plan Formulary |