ATGAM 50MG/ML AMPUL (5 X 5 ML AMP) (NDC: 00009722402)
2010 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
Plan Name |
Monthly Prem. |
De- duct- ible |
Does Plan Offer 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 |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,826.54 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,826.54 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,826.54 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,826.54 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,826.54 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,826.54 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,826.54 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,893.39 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,893.39 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,893.39 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,893.39 |
Browse Plan Formulary |
|
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,893.39 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,893.39 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,893.39 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,893.39 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,893.39 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,893.39 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,893.39 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,893.39 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$8.70 |
$0 |
to be determined |
5 |
Tier 5 |
25% | 25% | P | $2,793.64 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$8.70 |
$0 |
to be determined |
5 |
Tier 5 |
25% | 25% | P | $2,793.64 |
Browse Plan Formulary |
First Seniority Freedom - Drug (PFFS)
|
$17.00 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $2,865.81 |
Browse Plan Formulary |
First Seniority Freedom - Drug (PFFS)
|
$17.00 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $2,865.81 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
First Seniority Freedom - Drug (PFFS)
|
$17.00 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $2,865.81 |
Browse Plan Formulary |
First Seniority Freedom - Drug (PFFS)
|
$21.10 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $2,865.81 |
Browse Plan Formulary |
First Seniority Freedom - Drug (PFFS)
|
$21.10 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $2,865.81 |
Browse Plan Formulary |
First Seniority Freedom - Drug (PFFS)
|
$21.10 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $2,865.81 |
Browse Plan Formulary |
First Seniority Freedom - Drug (PFFS)
|
$21.10 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $2,865.81 |
Browse Plan Formulary |
First Seniority Freedom - Drug (PFFS)
|
$21.10 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $2,865.81 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
First Seniority Freedom - Drug (PFFS)
|
$21.10 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $2,865.81 |
Browse Plan Formulary |
First Seniority Freedom - Drug (PFFS)
|
$21.10 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $2,865.81 |
Browse Plan Formulary |
First Seniority Freedom - Drug (PFFS)
|
$21.10 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $2,865.81 |
Browse Plan Formulary |
First Seniority Freedom - Drug (PFFS)
|
$21.10 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $2,865.81 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,826.54 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,826.54 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,826.54 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,826.54 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,826.54 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,826.54 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,826.54 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,826.54 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,826.54 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,826.54 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,826.54 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,826.54 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,826.54 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,826.54 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,826.54 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,826.54 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,826.54 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,826.54 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,826.54 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,826.54 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,826.54 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $2,826.54 |
Browse Plan Formulary |
First Seniority Freedom Plus - Drug (PFFS)
|
$60.00 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $2,865.81 |
Browse Plan Formulary |
First Seniority Freedom Plus - Drug (PFFS)
|
$60.00 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $2,865.81 |
Browse Plan Formulary |
First Seniority Freedom Plus - Drug (PFFS)
|
$60.00 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $2,865.81 |
Browse Plan Formulary |
First Seniority Freedom Plus - Drug (PFFS)
|
$60.30 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $2,865.81 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
First Seniority Freedom Plus - Drug (PFFS)
|
$60.30 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $2,865.81 |
Browse Plan Formulary |
First Seniority Freedom Plus - Drug (PFFS)
|
$60.30 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $2,865.81 |
Browse Plan Formulary |
First Seniority Freedom Plus - Drug (PFFS)
|
$60.30 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $2,865.81 |
Browse Plan Formulary |
First Seniority Freedom Plus - Drug (PFFS)
|
$60.30 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $2,865.81 |
Browse Plan Formulary |
First Seniority Freedom Plus - Drug (PFFS)
|
$60.30 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $2,865.81 |
Browse Plan Formulary |
First Seniority Freedom Plus - Drug (PFFS)
|
$60.30 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $2,865.81 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
First Seniority Freedom Plus - Drug (PFFS)
|
$60.30 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $2,865.81 |
Browse Plan Formulary |
First Seniority Freedom Plus - Drug (PFFS)
|
$60.30 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $2,865.81 |
Browse Plan Formulary |