DEXTROSE INJECTION USP 5 4 X 100ML CTR (4 X 100 ML CTR) (NDC: 00409792337)
2011 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
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 |
AARP MedicareComplete Choice Plan 2 (Regional PPO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$45.00 | $125.00 | None | $163.90 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$10.00 | $20.00 | None | $162.30 |
Browse Plan Formulary |
AARP MedicareComplete Plus (HMO-POS)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$19.00 | $47.00 | None | $162.30 |
Browse Plan Formulary |
Advantage Health Florida (HMO SNP)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | None | $163.90 |
Browse Plan Formulary |
Advantage Silver South (HMO)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | None | $163.10 |
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 |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$4.00 | $8.00 | None | $160.71 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$15.00 | $30.00 | None | n/a |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$3.00 | $6.00 | None | n/a |
Browse Plan Formulary |
AvMed Medicare Choice (HMO)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | P | $127.47 |
Browse Plan Formulary |
BlueMedicare HMO (HMO)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
$6.00 | $0.00 | None | $201.69 |
Browse Plan Formulary |
CareDirect (HMO SNP)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | None | $2,033.50 |
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 |
CareFree Plus (HMO)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
$8.00 | $0.00 | None | n/a |
Browse Plan Formulary |
CareOne Plus (HMO)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | None | $2,033.50 |
Browse Plan Formulary |
Coventry Summit Ideal (HMO)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | None | $9.86 |
Browse Plan Formulary |
Coventry Summit Maximum (HMO SNP)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | None | $9.86 |
Browse Plan Formulary |
Coventry Summit Plus (HMO)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | None | $9.86 |
Browse Plan Formulary |
Coventry Vista Ideal (HMO)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | None | $9.86 |
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 |
Coventry Vista Maximum (HMO SNP)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | None | $9.86 |
Browse Plan Formulary |
Coventry Vista Maximum Choice (HMO SNP)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | None | $9.86 |
Browse Plan Formulary |
e-Any, Any, Any Gold Direct (PFFS)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$15.00 | $30.00 | None | n/a |
Browse Plan Formulary |
Freedom Medicare Plan Rx (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$0.00 | $0.00 | None | $161.38 |
Browse Plan Formulary |
Freedom VIP Care (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$20.00 | $40.00 | None | $161.38 |
Browse Plan Formulary |
Freedom VIP Care COPD (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$20.00 | $40.00 | None | $161.38 |
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 VIP Savings (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$20.00 | $40.00 | None | $161.38 |
Browse Plan Formulary |
Freedom VIP Savings COPD (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$20.00 | $40.00 | None | $161.38 |
Browse Plan Formulary |
Humana Gold Plus H1036-034A (HMO)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | None | $2,033.50 |
Browse Plan Formulary |
Humana Gold Plus H1036-054C (HMO)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | None | $2,033.50 |
Browse Plan Formulary |
Humana Gold Plus H5426-021 (HMO)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
$8.00 | $0.00 | None | n/a |
Browse Plan Formulary |
Humana Gold Plus SNP-DB H1036-125C (HMO SNP)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | None | $2,033.50 |
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 |
JacksonHealth for Life (HMO)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | None | $132.81 |
Browse Plan Formulary |
JacksonHealth Success (HMO SNP)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | None | $132.81 |
Browse Plan Formulary |
Leon Medical Centers Health Plans - Leon Cares (HMO)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
$0.00 | n/a | None | $2.25 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax (PSO)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
$0.00 | n/a | P | $164.99 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax Value RX (PSO)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
$0.00 | n/a | P | $165.79 |
Browse Plan Formulary |
Medicare Masterpiece (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$0.00 | $0.00 | None | $10.36 |
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 Masterpiece Premier (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$0.00 | $0.00 | None | $10.36 |
Browse Plan Formulary |
Medicare Masterpiece Premier SNP - COPD (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$0.00 | $0.00 | None | $10.36 |
Browse Plan Formulary |
Medicare Masterpiece Premier SNP - Dementia (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$0.00 | $0.00 | None | $10.36 |
Browse Plan Formulary |
Medicare Masterpiece Premier SNP - Diabetes (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$0.00 | $0.00 | None | $10.36 |
Browse Plan Formulary |
Medicare Masterpiece Premier SNP - Institutional (HMO SNP)
|
$0.00 |
$310 |
to be determined |
2 |
Tier 2 |
25% | 25% | None | $10.36 |
Browse Plan Formulary |
Molina Medicare Options Miami-Dade & Broward Co. (HMO)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | None | $160.74 |
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 |
Optimum Gold Plan (HMO-POS)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$39.00 | $78.00 | None | $161.38 |
Browse Plan Formulary |
Optimum Platinum Plan (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$39.00 | $78.00 | None | $161.38 |
Browse Plan Formulary |
POSITIVE HEALTHCARE PARTNERS (HMO SNP)
|
$0.00 |
$310 |
to be determined |
1 |
Tier 1 |
25% | n/a | P | $129.03 |
Browse Plan Formulary |
Preferred Care Partners Preferred Choice Dade (HMO-POS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$20.00 | $40.00 | None | $158.90 |
Browse Plan Formulary |
Preferred Care Partners Preferred Complete Care (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$20.00 | $40.00 | None | $158.90 |
Browse Plan Formulary |
Preferred Care Partners Preferred Medicare Assist (HMO SNP)
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $158.90 |
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 |
Preferred Care Partners Preferred PremiumAdvantage (HMO-POS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$60.00 | $120.00 | None | $158.90 |
Browse Plan Formulary |
Preferred Care Partners Preferred Special Care (HMO SNP)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$20.00 | $40.00 | None | $158.90 |
Browse Plan Formulary |
PUP Easy (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$0.00 | $0.00 | None | $162.30 |
Browse Plan Formulary |
PUP Rewards (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$0.00 | $0.00 | None | $163.10 |
Browse Plan Formulary |
SunPlus Advantage Plan (HMO)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
$0.00 | n/a | None | $139.38 |
Browse Plan Formulary |
Value One Florida (HMO SNP)
|
$0.00 |
$310 |
to be determined |
1 |
Tier 1 |
25% | 25% | None | $163.90 |
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 |
WellCare Choice (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$0.00 | $0.00 | None | $150.48 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$39.00 | $97.00 | None | $150.48 |
Browse Plan Formulary |
Freedom Medi-Medi (HMO SNP)
|
$8.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | None | $161.38 |
Browse Plan Formulary |
Optimum Emerald Partial (HMO SNP)
|
$11.40 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | None | $161.38 |
Browse Plan Formulary |
Optimum Emerald Full (HMO SNP)
|
$11.50 |
$310 |
to be determined |
2 |
Tier 2 |
n/a | n/a | None | $161.38 |
Browse Plan Formulary |
Medicare Masterpiece Plus (HMO-POS)
|
$13.90 |
$0 |
to be determined |
2 |
Tier 2 |
$15.00 | $30.00 | None | $10.36 |
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 Value Plan (HMO)
|
$16.10 |
$0 |
to be determined |
1 |
Tier 1: Preferred Generic Drugs |
$8.00 | $16.00 | None | $137.81 |
Browse Plan Formulary |
HumanaChoice H5415-056 (PPO)
|
$17.40 |
$0 |
to be determined |
1 |
Tier 1 |
$6.00 | $0.00 | None | n/a |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$20.30 |
$310 |
to be determined |
2 |
Tier 2 |
$45.00 | $112.00 | None | $159.28 |
Browse Plan Formulary |
HumanaChoice R5826-074 (Regional PPO)
|
$20.80 |
$310 |
to be determined |
1 |
Tier 1 |
25% | 25% | None | $2,255.10 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax Plus (PSO SNP)
|
$23.30 |
$310 |
to be determined |
1 |
Tier 1 |
$0.00 | n/a | P | $165.79 |
Browse Plan Formulary |
WellCare Select (HMO-POS SNP)
|
$23.30 |
$310 |
to be determined |
2 |
Tier 2 |
$44.00 | $110.00 | None | $163.28 |
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 |
CareNeeds (HMO SNP)
|
$24.30 |
$310 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | None | $2,033.50 |
Browse Plan Formulary |
Amerivantage Specialty + Rx (HMO SNP)
|
$25.40 |
$310 |
to be determined |
2 |
Tier 2 |
n/a | n/a | None | $156.71 |
Browse Plan Formulary |
CareNeeds Plus (HMO SNP)
|
$25.40 |
$310 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | None | $2,033.50 |
Browse Plan Formulary |
Evercare Plan RDP (Regional PPO SNP)
|
$25.40 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | None | $163.90 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-077A (HMO SNP)
|
$25.40 |
$310 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | None | $2,033.50 |
Browse Plan Formulary |
JacksonHealth Secure (HMO SNP)
|
$25.40 |
$310 |
to be determined |
1 |
Tier 1 |
n/a | n/a | None | $132.81 |
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 Masterpiece Premier SNP - Dual (HMO SNP)
|
$25.40 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | None | $10.36 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$25.40 |
$310* |
to be determined |
1* |
Tier 1 |
$0.00 | $0.00 | None | $161.54 |
Browse Plan Formulary |
UnitedHealthcare Personal Care Plus (HMO SNP)
|
$25.40 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | None | $162.30 |
Browse Plan Formulary |
Humana Gold Choice H8145-061 (PFFS)
|
$26.10 |
$0 |
to be determined |
1 |
Tier 1 |
$7.00 | $0.00 | None | n/a |
Browse Plan Formulary |
HumanaChoice R5826-005 (Regional PPO)
|
$28.50 |
$0 |
to be determined |
1 |
Tier 1 |
$8.00 | $0.00 | None | $2,255.10 |
Browse Plan Formulary |
BlueMedicare Regional PPO (Regional PPO)
|
$31.20 |
$150 |
to be determined |
1 |
Tier 1 |
$6.00 | $0.00 | None | $190.49 |
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 Standard Plan (PPO)
|
$36.00 |
$0 |
to be determined |
1 |
Tier 1: Preferred Generic Drugs |
$8.00 | $16.00 | None | $137.81 |
Browse Plan Formulary |