SPRITAM 250 MG TABLET (NDC: 43485010160)
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 Choice Plan 2 (Regional PPO)
![Email Prescription and/or Health Benefit details for AARP MedicareComplete Choice Plan 2 (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$395 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $517.30 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (HMO-POS)
![Email Prescription and/or Health Benefit details for Aetna Medicare Choice Plan (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $490.48 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Premier Plan (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $490.48 |
Browse Plan Formulary |
Allwell Medicare (HMO)
![Email Prescription and/or Health Benefit details for Allwell Medicare (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 |
$35.00 | n/a | P | $514.66 |
Browse Plan Formulary |
Allwell Medicare Premier (HMO)
![Email Prescription and/or Health Benefit details for Allwell Medicare Premier (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 |
$60.00 | n/a | P | $514.66 |
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 |
AvMed Medicare Choice (HMO)
![Email Prescription and/or Health Benefit details for AvMed Medicare Choice (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 Drug |
$75.00 | $187.50 | None | $512.84 |
Browse Plan Formulary |
BlueMedicare Classic (HMO)
![Email Prescription and/or Health Benefit details for BlueMedicare Classic (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 |
$93.00 | n/a | None | $493.45 |
Browse Plan Formulary |
BlueMedicare Premier (HMO)
![Email Prescription and/or Health Benefit details for BlueMedicare Premier (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 |
$65.00 | n/a | None | $493.45 |
Browse Plan Formulary |
CareFree PLUS (HMO)
![Email Prescription and/or Health Benefit details for CareFree PLUS (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 Drug |
$97.00 | $281.00 | S Q:360 /30Days | $488.48 |
Browse Plan Formulary |
CareOne PLUS (HMO)
![Email Prescription and/or Health Benefit details for CareOne PLUS (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 Drug |
$35.00 | $95.00 | S Q:360 /30Days | $488.48 |
Browse Plan Formulary |
Coventry Medicare Summit Plan (HMO)
![Email Prescription and/or Health Benefit details for Coventry Medicare Summit Plan (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 Drug |
$100.00 | $300.00 | None | $512.28 |
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 |
Coventry Medicare Vista Plan (HMO)
![Email Prescription and/or Health Benefit details for Coventry Medicare Vista Plan (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 Drug |
$100.00 | $300.00 | None | $512.28 |
Browse Plan Formulary |
Freedom Medicare Plan Rx (HMO)
![Email Prescription and/or Health Benefit details for Freedom Medicare Plan Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Drug |
$85.00 | n/a | Q:90 /30Days | $474.79 |
Browse Plan Formulary |
Freedom VIP Care (HMO SNP)
![Email Prescription and/or Health Benefit details for Freedom VIP Care (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Drug |
$75.00 | n/a | Q:90 /30Days | $474.79 |
Browse Plan Formulary |
Freedom VIP Savings (HMO SNP)
![Email Prescription and/or Health Benefit details for Freedom VIP Savings (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Drug |
$80.00 | n/a | Q:90 /30Days | $474.79 |
Browse Plan Formulary |
Freedom VIP Savings COPD (HMO SNP)
![Email Prescription and/or Health Benefit details for Freedom VIP Savings COPD (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Drug |
$80.00 | n/a | Q:90 /30Days | $474.79 |
Browse Plan Formulary |
HealthSun SunPlus Advantage Plan (HMO)
![Email Prescription and/or Health Benefit details for HealthSun SunPlus Advantage Plan (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 |
$25.00 | n/a | Q:120 /30Days | $475.27 |
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 |
Humana Gold Plus H1036-054C (HMO)
![Email Prescription and/or Health Benefit details for Humana Gold Plus H1036-054C (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 Drug |
$45.00 | $125.00 | S Q:360 /30Days | $488.39 |
Browse Plan Formulary |
Humana Gold Plus H1036-237 (HMO)
![Email Prescription and/or Health Benefit details for Humana Gold Plus H1036-237 (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 Drug |
$97.00 | $281.00 | S Q:360 /30Days | $488.39 |
Browse Plan Formulary |
Humana Gold Plus H1036-237 (HMO)
![Email Prescription and/or Health Benefit details for Humana Gold Plus H1036-237 (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 Drug |
$97.00 | $281.00 | S Q:360 /30Days | $488.39 |
Browse Plan Formulary |
HumanaChoice Florida H5216-068 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice Florida H5216-068 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:360 /30Days | $488.39 |
Browse Plan Formulary |
HumanaChoice R5826-074 (Regional PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice R5826-074 (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$405 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:360 /30Days | $478.63 |
Browse Plan Formulary |
Leon Medical Centers Health Plans - Leon Cares (HMO)
![Email Prescription and/or Health Benefit details for Leon Medical Centers Health Plans - Leon Cares (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand |
$0.00 | n/a | Q:60 /30Days | $499.38 |
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 |
Medica HealthCare Plans MedicareMax (HMO)
![Email Prescription and/or Health Benefit details for Medica HealthCare Plans MedicareMax (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 Drug |
$65.00 | $185.00 | None | $512.44 |
Browse Plan Formulary |
Optimum Gold Rewards Plan (HMO)
![Email Prescription and/or Health Benefit details for Optimum Gold Rewards Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Drug |
$85.00 | n/a | Q:90 /30Days | $474.79 |
Browse Plan Formulary |
Optimum Platinum Plan (HMO)
![Email Prescription and/or Health Benefit details for Optimum Platinum Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Drug |
$69.00 | n/a | Q:90 /30Days | $474.79 |
Browse Plan Formulary |
PHP (HMO SNP)
![Email Prescription and/or Health Benefit details for PHP (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
25% | n/a | S Q:120 /30Days | $480.76 |
Browse Plan Formulary |
Preferred Choice Dade (HMO)
![Email Prescription and/or Health Benefit details for Preferred Choice Dade (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 Drug |
$40.00 | $110.00 | None | $512.44 |
Browse Plan Formulary |
Preferred Special Care Miami-Dade (HMO SNP)
![Email Prescription and/or Health Benefit details for Preferred Special Care Miami-Dade (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$45.00 | $125.00 | None | $512.44 |
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 |
Simply Level (HMO SNP)
![Email Prescription and/or Health Benefit details for Simply Level (HMO SNP)](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 |
$10.00 | n/a | P Q:60 /30Days | $489.57 |
Browse Plan Formulary |
Simply More (HMO)
![Email Prescription and/or Health Benefit details for Simply More (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 |
$5.00 | n/a | P Q:60 /30Days | $489.57 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP ONE (Regional PPO SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Dual Complete RP ONE (Regional PPO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$405 |
to be determined |
4 |
Tier 4 |
$0.00 | n/a | None | $517.30 |
Browse Plan Formulary |
WellCare Dividend (HMO)
![Email Prescription and/or Health Benefit details for WellCare Dividend (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 Drug |
$50.00 | $125.00 | None | $522.13 |
Browse Plan Formulary |
WellCare Essential (HMO-POS)
![Email Prescription and/or Health Benefit details for WellCare Essential (HMO-POS)](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 Drug |
$75.00 | $187.50 | None | $486.93 |
Browse Plan Formulary |
WellCare Guardian (HMO SNP)
![Email Prescription and/or Health Benefit details for WellCare Guardian (HMO SNP)](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 Drug |
$50.00 | $125.00 | None | $522.13 |
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 |
CareNeeds PLUS (HMO SNP)
![Email Prescription and/or Health Benefit details for CareNeeds PLUS (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$6.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | S Q:360 /30Days | $488.48 |
Browse Plan Formulary |
CareNeeds (HMO SNP)
![Email Prescription and/or Health Benefit details for CareNeeds (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$11.20 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | S Q:360 /30Days | $488.48 |
Browse Plan Formulary |
CareExtra (HMO)
![Email Prescription and/or Health Benefit details for CareExtra (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$12.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
24% | 24% | S Q:360 /30Days | $488.48 |
Browse Plan Formulary |
Preferred Medicare Assist (HMO SNP)
![Email Prescription and/or Health Benefit details for Preferred Medicare Assist (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$16.00 |
$405 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | n/a | None | $512.44 |
Browse Plan Formulary |
Humana Value Plus H1036-264 (HMO)
![Email Prescription and/or Health Benefit details for Humana Value Plus H1036-264 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$16.30 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
24% | 24% | S Q:360 /30Days | $488.39 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-077A (HMO SNP)
![Email Prescription and/or Health Benefit details for Humana Gold Plus SNP-DE H1036-077A (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$17.40 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | S Q:360 /30Days | $488.39 |
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 |
UnitedHealthcare Dual Complete RP (Regional PPO SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Dual Complete RP (Regional PPO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$19.80 |
$405 |
to be determined |
4 |
Tier 4 |
15% | n/a | None | $517.30 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-257 (HMO SNP)
![Email Prescription and/or Health Benefit details for Humana Gold Plus SNP-DE H1036-257 (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$21.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | S Q:360 /30Days | $488.39 |
Browse Plan Formulary |
Coventry Medicare Summit Plan (HMO SNP)
![Email Prescription and/or Health Benefit details for Coventry Medicare Summit Plan (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$21.40 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | None | $514.26 |
Browse Plan Formulary |
UnitedHealthcare Assisted Living Plan (PPO SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Assisted Living Plan (PPO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$21.40 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $512.44 |
Browse Plan Formulary |
WellCare Select (HMO SNP)
![Email Prescription and/or Health Benefit details for WellCare Select (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$22.40 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $486.93 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax Plus (HMO SNP)
![Email Prescription and/or Health Benefit details for Medica HealthCare Plans MedicareMax Plus (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$25.20 |
$405 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | n/a | None | $512.44 |
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 |
WellCare Access (HMO SNP)
![Email Prescription and/or Health Benefit details for WellCare Access (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$28.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $522.13 |
Browse Plan Formulary |
Allwell Dual Medicare (HMO SNP)
![Email Prescription and/or Health Benefit details for Allwell Dual Medicare (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.00 |
$405 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | P | $514.66 |
Browse Plan Formulary |
BlueMedicare Complete (HMO SNP)
![Email Prescription and/or Health Benefit details for BlueMedicare Complete (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.10 |
$405 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | n/a | None | $493.92 |
Browse Plan Formulary |
Coventry Medicare Vista Plan (HMO SNP)
![Email Prescription and/or Health Benefit details for Coventry Medicare Vista Plan (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.10 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | n/a | None | $514.26 |
Browse Plan Formulary |
Freedom Medi-Medi Full (HMO SNP)
![Email Prescription and/or Health Benefit details for Freedom Medi-Medi Full (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Drug |
$95.00 | n/a | Q:90 /30Days | $474.79 |
Browse Plan Formulary |
Freedom Medi-Medi Partial (HMO SNP)
![Email Prescription and/or Health Benefit details for Freedom Medi-Medi Partial (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | Q:90 /30Days | $474.79 |
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 |
HealthSun MediMax (HMO)
![Email Prescription and/or Health Benefit details for HealthSun MediMax (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
25% | n/a | Q:120 /30Days | $475.27 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
![Email Prescription and/or Health Benefit details for Molina Medicare Options Plus (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.10 |
$405 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
47% | n/a | None | $474.50 |
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Optimum Emerald Full (HMO SNP)
![Email Prescription and/or Health Benefit details for Optimum Emerald Full (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Drug |
$95.00 | n/a | Q:90 /30Days | $474.79 |
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Optimum Emerald Partial (HMO SNP)
![Email Prescription and/or Health Benefit details for Optimum Emerald Partial (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Drug |
$95.00 | n/a | Q:90 /30Days | $474.79 |
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Simply Care (HMO SNP)
![Email Prescription and/or Health Benefit details for Simply Care (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.10 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$35.00 | n/a | P Q:60 /30Days | $489.57 |
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Simply Comfort (HMO SNP)
![Email Prescription and/or Health Benefit details for Simply Comfort (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.10 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$35.00 | n/a | P Q:60 /30Days | $489.57 |
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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 Complete (HMO SNP)
![Email Prescription and/or Health Benefit details for Simply Complete (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.10 |
$405 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$75.00 | n/a | P Q:60 /30Days | $488.68 |
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UnitedHealthcare Nursing Home Plan (PPO SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Nursing Home Plan (PPO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | None | $512.44 |
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WellCare Liberty (HMO SNP)
![Email Prescription and/or Health Benefit details for WellCare Liberty (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $522.13 |
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HumanaChoice R5826-005 (Regional PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice R5826-005 (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$33.60 |
$100 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:360 /30Days | $478.63 |
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UnitedHealthcare Nursing Home Plan (HMO SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Nursing Home Plan (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$34.90 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | None | $512.44 |
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BlueMedicare Choice (Regional PPO)
![Email Prescription and/or Health Benefit details for BlueMedicare Choice (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$41.00 |
$260 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | n/a | None | $479.10 |
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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 H5216-065 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice H5216-065 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$57.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | S Q:360 /30Days | $488.39 |
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Humana Gold Choice H8145-061 (PFFS)
![Email Prescription and/or Health Benefit details for Humana Gold Choice H8145-061 (PFFS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$117.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | S Q:360 /30Days | $488.39 |
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