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 |
Aetna Medicare Rx Essentials (PDP)
|
$21.00 |
$310 |
No Gap Coverage |
4 |
Tier 4 - Non-Preferred Brand |
$69.00 | $192.00 | None | $3,785.32 |
Browse Plan Formulary |
PrescribaRx Bronze (PDP)
|
$23.20 |
$310 |
No Gap Coverage |
2 |
Tier 2 |
25% | 25% | P | $3,856.19 |
Browse Plan Formulary |
AARP MedicareRx Saver (PDP)
|
$23.50 |
$310 |
No Gap Coverage |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$80.00 | $225.00 | None | $3,920.60 |
Browse Plan Formulary |
UnitedHealthcare MedicareRx (PDP)
|
$23.50 |
$310 |
No Gap Coverage |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$70.00 | $195.00 | None | $3,920.60 |
Browse Plan Formulary |
First Health Part D-Premier (PDP)
|
$24.80 |
$150 |
No Gap Coverage |
3 |
Non-Preferred Generic/Non-Preferred Brand |
44% | 44% | P | $3,878.92 |
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)
|
$25.00 |
$310 |
No Gap Coverage |
3 |
Tier 3 |
$77.00 | $192.50 | P | $3,828.17 |
Browse Plan Formulary |
HealthSpring Prescription Drug Plan-Reg 22
|
$25.40 |
$310 |
No Gap Coverage |
2 |
Tier 2 |
25% | 25% | P | $3,833.89 |
Browse Plan Formulary |
Community CCRx Basic (PDP)
|
$25.70 |
$310 |
No Gap Coverage |
3 |
Non-Preferred Brand |
70% | n/a | P | $3,958.79 |
Browse Plan Formulary |
EnvisionRxPlus Silver (PDP)
|
$25.70 |
$310 |
No Gap Coverage |
4 |
Tier 4 |
25% | 25% | None | $3,815.45 |
Browse Plan Formulary |
Aetna Medicare Rx Plus (PDP)
|
$25.80 |
$0 |
No Gap Coverage |
4 |
Tier 4 - Non-Preferred Brand |
$80.00 | $225.00 | None | $3,785.32 |
Browse Plan Formulary |
BravoRx (PDP)
|
$26.70 |
$310 |
No Gap Coverage |
2 |
Tier 2 |
25% | 25% | P | $3,848.97 |
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 |
Humana Basic S5884-121 (PDP)
|
$27.90 |
$310 |
No Gap Coverage |
3 |
Non-Preferred Brand |
29% | 29% | None | $3,746.98 |
Browse Plan Formulary |
MedicareRx Rewards Standard (PDP)
|
$28.30 |
$310 |
No Gap Coverage |
3 |
Tier 3 Non-Specialty Injectable Drugs |
25% | 25% | None | $3,277.97 |
Browse Plan Formulary |
Advantage Star Plan by RxAmerica (PDP)
|
$29.40 |
$310 |
No Gap Coverage |
4 |
Non-Preferred |
45% | 45% | P | $3,979.36 |
Browse Plan Formulary |
Health Net Orange Option 1 (PDP)
|
$29.40 |
$310 |
No Gap Coverage |
4 |
Tier 4 Injectable |
25% | n/a | None | $3,784.86 |
Browse Plan Formulary |
SilverScript Value (PDP)
|
$29.40 |
$310 |
No Gap Coverage |
2 |
Preferred Brand Tier |
$22.50 | $56.25 | None | $3,834.34 |
Browse Plan Formulary |
Blue MedicareRx Value (PDP)
|
$33.30 |
$0 |
No Gap Coverage |
3 |
Brand |
$88.00 | $220.00 | None | $3,808.73 |
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 |
UA Medicare Part D Rx Covg - Silver Plan (
|
$34.30 |
$140 |
No Gap Coverage |
2 |
Preferred Brand |
$45.00 | $113.00 | None | $3,785.53 |
Browse Plan Formulary |
CIGNA Medicare Rx Plan Two (PDP)
|
$34.40 |
$100 |
No Gap Coverage |
4 |
Tier 4 |
$93.00 | $232.50 | P | $3,828.17 |
Browse Plan Formulary |
PrescribaRx Gold (PDP)
|
$37.80 |
$150 |
No Gap Coverage |
2 |
Brand |
$43.00 | $86.00 | P | $3,856.19 |
Browse Plan Formulary |
Blue MedicareRx Standard (PDP)
|
$39.00 |
$310 |
No Gap Coverage |
3 |
Brand |
$83.00 | $207.50 | None | $3,808.73 |
Browse Plan Formulary |
AARP MedicareRx Preferred (PDP)
|
$41.00 |
$0 |
No Gap Coverage |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$64.00 | $177.00 | None | $3,920.60 |
Browse Plan Formulary |
Humana Enhanced S5884-020 (PDP)
|
$41.40 |
$0 |
No Gap Coverage |
3 |
Non-Preferred Brand |
$80.00 | $200.00 | None | $3,746.98 |
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 |
AdvantraRx Value (PDP)
|
$41.80 |
$100 |
No Gap Coverage |
3 |
Non-Preferred Generic and Non-Preferred Brand |
64% | 64% | P | $3,878.92 |
Browse Plan Formulary |
Community CCRx Choice (PDP)
|
$42.20 |
$150 |
No Gap Coverage |
3 |
Non-Preferred Brand |
$65.00 | n/a | P | $3,958.79 |
Browse Plan Formulary |
Scott and White Health Plan Texas Rx Value
|
$44.50 |
$310 |
No Gap Coverage |
3 |
Non-Preferred Brand or Generic |
$60.00 | $120.00 | P | $3,831.70 |
Browse Plan Formulary |
MedicareRx Rewards Plus (PDP)
|
$46.30 |
$0 |
No Gap Coverage |
4 |
Tier 4 Non-Specialty Injectable Drugs |
33% | 33% | None | $3,277.97 |
Browse Plan Formulary |
Scott and White Health Plan Texas Rx Basic
|
$46.40 |
$0 |
No Gap Coverage |
3 |
Non-Preferred Brand or Generic |
$65.00 | $130.00 | P | $3,831.70 |
Browse Plan Formulary |
First Health Part D-Secure (PDP)
|
$47.20 |
$175 |
No Gap Coverage |
3 |
Non-Preferred Generic and Non-Preferred Brand |
53% | 53% | P | $3,788.24 |
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 - Value (
|
$47.70 |
$310 |
No Gap Coverage |
2 |
Tier 2 |
25% | 25% | None | $3,830.75 |
Browse Plan Formulary |
Medco Medicare Prescription Plan - Choice
|
$49.80 |
$100 |
No Gap Coverage |
2 |
Preferred Brand |
$39.00 | $97.50 | None | $3,830.75 |
Browse Plan Formulary |
UA Medicare Part D Prescription Drug Cov (
|
$50.70 |
$0 |
No Gap Coverage |
2 |
Preferred Brand |
$38.00 | $76.00 | None | $3,785.53 |
Browse Plan Formulary |
AdvantraRx Premier (PDP)
|
$51.90 |
$0 |
No Gap Coverage |
3 |
Non-Preferred Generic and Non-Preferred Brand |
52% | 52% | P | $3,878.92 |
Browse Plan Formulary |
Advantage Freedom Plan by RxAmerica (PDP)
|
$54.30 |
$0 |
No Gap Coverage |
5 |
Non-Preferred |
45% | 45% | P | $3,970.91 |
Browse Plan Formulary |
CVS Caremark Plus (PDP)
|
$60.70 |
$50 |
No Gap Coverage |
4 |
Preferred Brand Tier |
$30.00 | $75.00 | None | $3,824.83 |
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 |
Sterling Rx (PDP)
|
$61.40 |
$310 |
No Gap Coverage |
2 |
Brand |
$29.00 | $58.00 | None | $3,255.96 |
Browse Plan Formulary |
EnvisionRxPlus Gold (PDP)
|
$63.40 |
$150 |
No Gap Coverage |
4 |
Tier 4 NonPreferred Brand |
25% | 25% | None | $3,815.45 |
Browse Plan Formulary |
Health Net Orange Option 2 (PDP)
|
$66.40 |
$0 |
No Gap Coverage |
4 |
Tier 4 Injectable |
33% | n/a | None | $3,784.86 |
Browse Plan Formulary |
CIGNA Medicare Rx Plan Three (PDP)
|
$66.50 |
$0 |
Many Generics, Few Brands |
3 |
Tier 3 |
$60.00 | $150.00 | P | $3,828.17 |
Browse Plan Formulary |
Blue MedicareRx Plus (PDP)
|
$67.50 |
$0 |
Many Generics |
3 |
Brand |
$75.00 | $187.50 | None | $3,808.73 |
Browse Plan Formulary |
AdvantraRx Premier Plus (PDP)
|
$68.80 |
$0 |
Many Generics |
4 |
Non-Preferred Brand |
75% | 75% | P | $3,878.92 |
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 |
Aetna Medicare Rx Premier (PDP)
|
$74.80 |
$0 |
Many Generics |
4 |
Tier 4 - Non-Preferred Brand |
$81.00 | $228.00 | None | $3,785.32 |
Browse Plan Formulary |
Community CCRx Gold (PDP)
|
$75.70 |
$0 |
All Generics |
3 |
Non-Preferred Brand |
$65.00 | n/a | P | $3,958.79 |
Browse Plan Formulary |
AARP MedicareRx Enhanced (PDP)
|
$76.20 |
$0 |
Many Generics |
3 |
Tier 3 Non-Preferred Generic Non-Preferred Brand |
$90.00 | $255.00 | None | $3,920.60 |
Browse Plan Formulary |
CVS Caremark Complete (PDP)
|
$81.90 |
$0 |
Many Generics |
3 |
Preferred Brand Tier |
$39.00 | $98.00 | None | $3,865.36 |
Browse Plan Formulary |
Medco Medicare Prescription Plan - Access
|
$86.00 |
$0 |
Many Generics |
2 |
Preferred Brand |
$40.00 | $100.00 | None | $3,830.75 |
Browse Plan Formulary |
Humana Complete S5884-050 (PDP)
|
$94.90 |
$0 |
Many Generics |
3 |
Non-Preferred Brand |
$75.00 | $187.50 | None | $3,746.98 |
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 |
Scott and White Health PlanTexas Rx Enhanc
|
$113.40 |
$0 |
Many Generics |
3 |
Non-Preferred Brand or Generic |
$65.00 | $130.00 | P | $3,831.70 |
Browse Plan Formulary |