TRISENOX 10MG/10ML AMPULE (10 AMP) (NDC: 63459060010)
2010 Medicare Prescription Drug Plan (PDP) 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 |
First Health Part D-Secure (PDP)
|
$16.70 |
$175 |
No Gap Coverage |
3 |
Non-Preferred Generic and Non-Preferred Brand |
52% | 52% | P | $3,788.24 |
Browse Plan Formulary |
Community CCRx Basic (PDP)
|
$20.60 |
$310 |
No Gap Coverage |
3 |
Non-Preferred Brand |
65% | n/a | P | $3,958.79 |
Browse Plan Formulary |
PrescribaRx Bronze (PDP)
|
$24.30 |
$310 |
No Gap Coverage |
2 |
Tier 2 |
25% | 25% | P | $3,856.19 |
Browse Plan Formulary |
Humana Value S5884-104 (PDP)
|
$26.70 |
$150 |
No Gap Coverage |
3 |
Non-Preferred Brand |
36% | 36% | None | $3,746.98 |
Browse Plan Formulary |
AARP MedicareRx Saver (PDP)
|
$27.10 |
$310 |
No Gap Coverage |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$82.75 | $233.25 | None | $3,920.60 |
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 Rx Plan One (PDP)
|
$28.10 |
$310 |
No Gap Coverage |
3 |
Tier 3 |
$90.00 | $225.00 | P | $3,828.17 |
Browse Plan Formulary |
AdvantraRx Value (PDP)
|
$29.20 |
$100 |
No Gap Coverage |
3 |
Non-Preferred Generic and Non-Preferred Brand |
65% | 65% | P | $3,878.92 |
Browse Plan Formulary |
Medco Medicare Prescription Plan - Value (
|
$29.90 |
$310 |
No Gap Coverage |
2 |
Tier 2 |
25% | 25% | None | $3,830.75 |
Browse Plan Formulary |
AmeriHealth Advantage (PDP)
|
$30.10 |
$310 |
No Gap Coverage |
4 |
Tier 4 |
25% | n/a | P | $3,863.00 |
Browse Plan Formulary |
BravoRx (PDP)
|
$30.70 |
$310 |
No Gap Coverage |
2 |
Tier 2 |
25% | 25% | P | $3,848.97 |
Browse Plan Formulary |
Fox Value Plan (PDP)
|
$30.90 |
$310 |
No Gap Coverage |
4 |
Tier 4 |
60% | 50% | P | n/a |
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 |
Health Net Orange Option 1 (PDP)
|
$30.90 |
$310 |
No Gap Coverage |
4 |
Tier 4 Injectable |
25% | n/a | None | $3,769.71 |
Browse Plan Formulary |
SilverScript Value (PDP)
|
$31.60 |
$310 |
No Gap Coverage |
2 |
Preferred Brand Tier |
$21.00 | $52.50 | None | $3,800.66 |
Browse Plan Formulary |
Advantage Star Plan by RxAmerica (PDP)
|
$31.70 |
$310 |
No Gap Coverage |
4 |
Non-Preferred |
45% | 45% | P | $3,979.36 |
Browse Plan Formulary |
PrescribaRx Gold (PDP)
|
$32.10 |
$150 |
No Gap Coverage |
2 |
Brand |
$43.00 | $86.00 | P | $3,856.19 |
Browse Plan Formulary |
HealthSpring Prescription Drug Plan -Reg 6
|
$32.50 |
$310 |
No Gap Coverage |
2 |
Tier 2 |
25% | 25% | P | $3,833.89 |
Browse Plan Formulary |
MedicareRx Rewards Standard (PDP)
|
$32.80 |
$310 |
No Gap Coverage |
3 |
Tier 3 Non-Specialty Injectable Drugs |
25% | 25% | None | $3,277.97 |
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 |
EnvisionRxPlus Silver (PDP)
|
$33.00 |
$310 |
No Gap Coverage |
4 |
Tier 4 |
25% | 25% | None | $3,815.45 |
Browse Plan Formulary |
CIGNA Medicare Rx Plan Two (PDP)
|
$33.60 |
$100 |
No Gap Coverage |
4 |
Tier 4 |
$82.00 | $205.00 | P | $3,828.17 |
Browse Plan Formulary |
MedicareRx Rewards Plus (PDP)
|
$33.90 |
$0 |
No Gap Coverage |
4 |
Tier 4 Non-Specialty Injectable Drugs |
33% | 33% | None | $3,277.97 |
Browse Plan Formulary |
Community CCRx Choice (PDP)
|
$35.40 |
$150 |
No Gap Coverage |
3 |
Non-Preferred Brand |
$65.00 | n/a | P | $3,958.79 |
Browse Plan Formulary |
Aetna Medicare Rx Plus (PDP)
|
$36.70 |
$0 |
No Gap Coverage |
4 |
Tier 4 - Non-Preferred Brand |
$80.00 | $225.00 | None | $3,785.32 |
Browse Plan Formulary |
AARP MedicareRx Preferred (PDP)
|
$37.40 |
$0 |
No Gap Coverage |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None | $3,920.60 |
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 |
Medco Medicare Prescription Plan - Choice
|
$38.90 |
$100 |
No Gap Coverage |
2 |
Preferred Brand |
$39.00 | $97.50 | None | $3,830.75 |
Browse Plan Formulary |
First Health Part D-Premier (PDP)
|
$40.00 |
$150 |
No Gap Coverage |
3 |
Non-Preferred Generic/Non-Preferred Brand |
43% | 43% | P | $3,878.92 |
Browse Plan Formulary |
AdvantraRx Premier (PDP)
|
$41.00 |
$0 |
No Gap Coverage |
3 |
Non-Preferred Generic and Non-Preferred Brand |
52% | 52% | P | $3,878.92 |
Browse Plan Formulary |
Humana Enhanced S5884-005 (PDP)
|
$41.20 |
$0 |
No Gap Coverage |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None | $3,746.98 |
Browse Plan Formulary |
UA Medicare Part D Rx Covg - Silver Plan (
|
$41.90 |
$170 |
No Gap Coverage |
2 |
Preferred Brand |
$45.00 | $113.00 | None | $3,785.53 |
Browse Plan Formulary |
Sterling Rx (PDP)
|
$45.20 |
$310 |
No Gap Coverage |
2 |
Brand |
$29.00 | $58.00 | None | $3,255.96 |
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 |
CVS Caremark Plus (PDP)
|
$45.40 |
$50 |
No Gap Coverage |
4 |
Preferred Brand Tier |
$30.00 | $75.00 | None | $3,792.38 |
Browse Plan Formulary |
UA Medicare Part D Prescription Drug Cov (
|
$46.10 |
$0 |
No Gap Coverage |
2 |
Preferred Brand |
$38.00 | $76.00 | None | $3,785.53 |
Browse Plan Formulary |
SecureRx - Option 4 (PDP)
|
$47.30 |
$310 |
No Gap Coverage |
2 |
Tier 2 |
25% | 25% | None | $3,228.52 |
Browse Plan Formulary |
Advantage Freedom Plan by RxAmerica (PDP)
|
$49.00 |
$0 |
No Gap Coverage |
5 |
Non-Preferred |
45% | 45% | P | $3,970.91 |
Browse Plan Formulary |
Aetna Medicare Rx Essentials (PDP)
|
$49.00 |
$310 |
No Gap Coverage |
4 |
Tier 4 - Non-Preferred Brand |
$68.00 | $189.00 | None | $3,785.32 |
Browse Plan Formulary |
SecureRx - Option 3 (PDP)
|
$49.00 |
$0 |
No Gap Coverage |
2 |
Formulary Brand Drugs |
$45.00 | $112.00 | None | $3,228.52 |
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 |
Geisinger Gold Rx 1 (PDP)
|
$50.40 |
$310 |
No Gap Coverage |
2 |
Tier 2 |
25% | 25% | None | $3,830.82 |
Browse Plan Formulary |
BlueRx Plus (PDP)
|
$51.30 |
$0 |
No Gap Coverage |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | None | $3,822.79 |
Browse Plan Formulary |
Health Net Value Orange Option 2 (PDP)
|
$51.70 |
$0 |
No Gap Coverage |
4 |
Tier 4 Injectable |
33% | n/a | None | $3,769.71 |
Browse Plan Formulary |
UPMC for Life (PDP)
|
$52.30 |
$0 |
No Gap Coverage |
3 |
Tier 3 - Non-Preferred Brand |
$80.00 | $200.00 | None | $3,232.47 |
Browse Plan Formulary |
EnvisionRxPlus Gold (PDP)
|
$54.80 |
$150 |
No Gap Coverage |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None | $3,815.45 |
Browse Plan Formulary |
BlueRx Value (PDP)
|
$56.20 |
$310 |
No Gap Coverage |
3 |
Non Preferred Brand |
$63.00 | $157.50 | None | $3,822.79 |
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 Rx Plan Three (PDP)
|
$57.40 |
$0 |
Many Generics, Few Brands |
3 |
Tier 3 |
$60.00 | $150.00 | P | $3,828.17 |
Browse Plan Formulary |
AdvantraRx Premier Plus (PDP)
|
$61.20 |
$0 |
Many Generics |
4 |
Non-Preferred Brand |
75% | 75% | P | $3,878.92 |
Browse Plan Formulary |
AmeriHealth Rx Option I (PDP)
|
$65.50 |
$310 |
No Gap Coverage |
4 |
Tier 4 |
25% | 25% | None | $3,931.43 |
Browse Plan Formulary |
AmeriHealth Rx Option II (PDP)
|
$66.70 |
$100 |
Many Generics |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None | $3,931.43 |
Browse Plan Formulary |
CVS Caremark Complete (PDP)
|
$66.90 |
$0 |
Many Generics |
3 |
Preferred Brand Tier |
$39.00 | $98.00 | None | $3,854.81 |
Browse Plan Formulary |
Medco Medicare Prescription Plan - Access
|
$73.80 |
$0 |
Many Generics |
2 |
Preferred Brand |
$40.00 | $100.00 | None | $3,830.75 |
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 |
Community CCRx Gold (PDP)
|
$77.30 |
$0 |
All Generics |
3 |
Non-Preferred Brand |
$65.00 | n/a | P | $3,958.79 |
Browse Plan Formulary |
AARP MedicareRx Enhanced (PDP)
|
$81.10 |
$0 |
Many Generics |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None | $3,920.60 |
Browse Plan Formulary |
Aetna Medicare Rx Premier (PDP)
|
$83.70 |
$0 |
Many Generics |
4 |
Tier 4 - Non-Preferred Brand |
$86.00 | $243.00 | None | $3,785.32 |
Browse Plan Formulary |
BlueRx Complete (PDP)
|
$93.90 |
$0 |
Many Generics |
3 |
Non-Preferred Brand |
$70.00 | $175.00 | None | $3,822.79 |
Browse Plan Formulary |
Humana Complete S5884-034 (PDP)
|
$100.10 |
$0 |
Many Generics |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None | $3,746.98 |
Browse Plan Formulary |
SecureRx - Option 1 (PDP)
|
$110.70 |
$0 |
Many Generics |
2 |
Preferred Brand Drugs |
$35.00 | $85.00 | None | $3,228.52 |
Browse Plan Formulary |