COMBIVENT RESPIMAT INHAL SPRAY (4 GM ) (NDC: 00597002402)
2021 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 |
Aetna Medicare Advantra Credit Value (PPO)
|
$0.00 |
$250 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:8 /30Days | $468.32 |
Browse Plan Formulary |
Aetna Medicare Advantra Gold (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:8 /30Days | $468.36 |
Browse Plan Formulary |
Aetna Medicare Advantra Silver (PPO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:8 /30Days | $468.28 |
Browse Plan Formulary |
Aetna Medicare Value (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:8 /30Days | $468.28 |
Browse Plan Formulary |
Allwell Medicare (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:8 /30Days | $468.64 |
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 |
Allwell Medicare (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:8 /30Days | $468.56 |
Browse Plan Formulary |
Allwell Medicare Boost (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:8 /30Days | $468.68 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | Q:4 /30Days | $439.32 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | Q:4 /30Days | $438.16 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | Q:4 /30Days | $437.00 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | Q:4 /30Days | $440.48 |
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 |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | Q:4 /30Days | $433.36 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | Q:4 /30Days | $433.28 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | Q:4 /30Days | $432.32 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | Q:4 /30Days | $435.76 |
Browse Plan Formulary |
Geisinger Gold Classic 360 Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.44 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.56 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
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 |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.56 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.32 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.56 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
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 |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.32 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.56 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.56 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.56 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
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 |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H6622-036 (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:4 /20Days | $468.32 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5525-038 (PPO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:4 /20Days | $468.00 |
Browse Plan Formulary |
Vibra Essential Advocate (PPO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | Q:8 /30Days | $433.04 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
Vibra Essential Advocate (PPO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | Q:8 /30Days | $432.16 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
Humana Gold Choice H8145-052 (PFFS)
|
$8.00 |
$360 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:4 /20Days | $468.56 |
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 Advantra Silver Plus (PPO)
|
$19.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:8 /30Days | $468.28 |
Browse Plan Formulary |
Aetna Medicare Advantra Premier (HMO)
|
$25.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:8 /30Days | $468.28 |
Browse Plan Formulary |
Vibra Health Plan Enhanced Complete (PPO)
|
$26.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | Q:8 /30Days | $432.64 |
Browse Plan Formulary select insulin pay $5 copay but not this drug |
Humana Gold Plus SNP-DE H6622-038 (HMO D-SNP)
|
$26.10 |
$445 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:4 /20Days | $468.32 |
Browse Plan Formulary |
Aetna Medicare Advantra Cares (HMO D-SNP)
|
$27.30 |
$220 |
No |
4 |
Non-Preferred Drug |
35% | 35% | Q:8 /30Days | $468.24 |
Browse Plan Formulary |
Allwell Medicare Complement (HMO)
|
$29.50 |
$445 |
No |
4 |
Non-Preferred Drug |
50% | 50% | Q:8 /30Days | $468.68 |
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 R0923-002 (Regional PPO)
|
$29.60 |
$0 |
No |
4 |
Non-Preferred Drug |
$99.00 | $287.00 | Q:4 /20Days | $467.92 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$30.10 |
$445 |
No |
3 |
Tier 3 |
$0.00 | $0.00 | Q:4 /20Days | $472.68 |
Browse Plan Formulary |
Allwell Dual Medicare (HMO D-SNP)
|
$34.20 |
$445 |
No |
4 |
Non-Preferred Drug |
48% | 48% | Q:8 /30Days | $468.52 |
Browse Plan Formulary |
Community Blue Medicare PPO Distinct (PPO)
|
$35.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | Q:4 /30Days | $433.36 |
Browse Plan Formulary |
Community Blue Medicare PPO Distinct (PPO)
|
$35.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | Q:4 /30Days | $433.28 |
Browse Plan Formulary |
Community Blue Medicare PPO Distinct (PPO)
|
$35.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | Q:4 /30Days | $432.32 |
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 |
Community Blue Medicare PPO Distinct (PPO)
|
$35.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $275.00 | Q:4 /30Days | $435.76 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
|
$37.20 |
$445 |
No |
3 |
Tier 3 |
25% | 25% | Q:4 /20Days | $472.56 |
Browse Plan Formulary |
AmeriHealth Caritas VIP Care (HMO D-SNP)
|
$37.40 |
$445 |
No |
2 |
Brand |
25% | 25% | S | $435.76 |
Browse Plan Formulary |
Geisinger Gold Secure Rx (HMO D-SNP)
|
$37.50 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | None | $426.36 |
Browse Plan Formulary |
UPMC for Life Complete Care (HMO D-SNP)
|
$37.50 |
$445 |
No |
3 |
Preferred Brand |
$18.00 | $45.00 | None | $434.76 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
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 |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.32 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.56 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.56 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.56 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Advantra Premier Plus (PPO)
|
$47.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$99.00 | $297.00 | Q:8 /30Days | $468.32 |
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 H5525-007 (PPO)
|
$54.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:4 /20Days | $468.24 |
Browse Plan Formulary |
Aetna Medicare Silver (HMO)
|
$69.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:8 /30Days | $468.32 |
Browse Plan Formulary |
Freedom Blue PPO ValueRx (PPO)
|
$70.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:4 /30Days | $433.28 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$110.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$110.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.32 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$110.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.56 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
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 |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$110.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$110.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.56 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$110.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.56 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$121.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$121.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.32 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$121.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.56 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
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 |
Geisinger Gold Classic Advantage Rx (HMO)
|
$121.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$121.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.56 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Geisinger Gold Classic Advantage Rx (HMO)
|
$121.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $70.50 | None | $426.56 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5216-120 (PPO)
|
$127.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:4 /20Days | $468.04 |
Browse Plan Formulary |
Aetna Medicare Gold Plan (PPO)
|
$169.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:8 /30Days | $468.32 |
Browse Plan Formulary |
Freedom Blue PPO Standard (PPO)
|
$175.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:4 /30Days | $433.28 |
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 |
Freedom Blue PPO Deluxe (PPO)
|
$289.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:4 /30Days | $433.28 |
Browse Plan Formulary |