SYMPAZAN 5 MG FILM (1 unit ) (NDC: 10094020560)
2019 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
See your cost using a drug discount card: Compare prices at pharmacies near you |
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 |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $823.57 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $782.89 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $782.89 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $782.89 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $782.89 |
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 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $782.89 |
Browse Plan Formulary |
HAP Senior Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:240 /30Days | $784.72 |
Browse Plan Formulary |
MeridianCare Essential (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:60 /30Days | $792.71 |
Browse Plan Formulary |
Paramount Elite - Standard Medical and Drug (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | P | $835.50 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:60 /30Days | $784.85 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:60 /30Days | $784.85 |
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 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:60 /30Days | $784.85 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:60 /30Days | $784.85 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:60 /30Days | $784.85 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$14.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $782.81 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$14.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $782.81 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$14.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $782.81 |
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)
|
$14.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $782.81 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$14.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $782.81 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:60 /30Days | $784.85 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:60 /30Days | $784.85 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:60 /30Days | $784.85 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:60 /30Days | $784.85 |
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)
|
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:60 /30Days | $784.85 |
Browse Plan Formulary |
HAP Senior Plus Option 1 (PPO)
|
$15.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:240 /30Days | $784.72 |
Browse Plan Formulary |
HumanaChoice H8087-001 (PPO)
|
$20.00 |
$195 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | P Q:60 /30Days | $807.89 |
Browse Plan Formulary |
HumanaChoice R3887-002 (Regional PPO)
|
$20.50 |
$150 |
to be determined |
5 |
Specialty Tier |
30% | n/a | P Q:60 /30Days | $807.89 |
Browse Plan Formulary |
Humana Value Plus H8087-002 (PPO)
|
$23.90 |
$260 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | P Q:60 /30Days | $807.89 |
Browse Plan Formulary |
Paramount Elite - Prime Medical and Drug (HMO)
|
$28.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | P | $835.50 |
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 |
MeridianCare Extra (HMO SNP)
|
$32.90 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
25% | 25% | Q:60 /30Days | $792.71 |
Browse Plan Formulary |
HAP Senior Plus Option 1 (HMO-POS)
|
$45.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:240 /30Days | $784.72 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$47.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $823.57 |
Browse Plan Formulary |
HAP Senior Plus Option 2 (PPO)
|
$55.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:240 /30Days | $784.72 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$61.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | P Q:60 /30Days | $784.85 |
Browse Plan Formulary |
Paramount Elite - Enhanced Medical and Drug (HMO)
|
$68.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | P | $835.50 |
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)
|
$73.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $782.81 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$73.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $782.81 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$73.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $782.81 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$73.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $782.81 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$73.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $782.81 |
Browse Plan Formulary |
HAP Senior Plus Option 2 (HMO-POS)
|
$75.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:240 /30Days | $784.72 |
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 H5216-009 (PPO)
|
$75.00 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | P Q:60 /30Days | $807.89 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$81.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | P Q:60 /30Days | $784.85 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$81.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | P Q:60 /30Days | $784.85 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$81.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | P Q:60 /30Days | $784.85 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$81.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | P Q:60 /30Days | $784.85 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$81.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | P Q:60 /30Days | $784.85 |
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 |
Aetna Medicare Premier Plan (PPO)
|
$87.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $823.57 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$110.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $782.89 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$110.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $782.89 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$110.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $782.89 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$110.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $782.89 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$110.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $782.89 |
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 |
HAP Senior Plus Option 3 (PPO)
|
$118.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | P Q:240 /30Days | $784.72 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$153.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $784.85 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$160.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $782.81 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$160.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $782.81 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$160.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $782.81 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$160.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $782.81 |
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)
|
$160.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $782.81 |
Browse Plan Formulary |
HAP Senior Plus Option 3 (HMO-POS)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | P Q:240 /30Days | $784.72 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$170.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $784.85 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$170.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $784.85 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$170.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $784.85 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$170.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $784.85 |
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)
|
$170.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $784.85 |
Browse Plan Formulary |
HAP Senior Plus Option 4 (PPO)
|
$190.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
45% | 45% | P Q:240 /30Days | $784.72 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$270.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $782.81 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$270.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $782.81 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$270.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $782.81 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$270.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $782.81 |
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)
|
$270.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $782.81 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$287.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $782.89 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$287.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $782.89 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$287.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $782.89 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$287.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $782.89 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$287.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $782.89 |
Browse Plan Formulary |