AMIFOSTINE FOR INJECTION 500MG/VIAL (3 X 10ML VIALSU) (NDC: 62756058142)
2012 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 SecureHorizons (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | None | $1,443.18 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | None | $1,443.18 |
Browse Plan Formulary |
Advantage I MAPD (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Tier 4 |
33% | 33% | P | $1,481.39 |
Browse Plan Formulary |
Advantage I MAPD (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Tier 4 |
33% | 33% | P | $1,481.39 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
$33.00 | $66.00 | P | $1,443.72 |
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 Select Plan (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
$33.00 | $66.00 | P | $1,443.72 |
Browse Plan Formulary |
Anthem Medicare Preferred Standard (PPO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,251.74 |
Browse Plan Formulary |
Blue Cross Senior Secure Plan I (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,251.74 |
Browse Plan Formulary |
Blue Cross Senior Secure Plan I (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,251.74 |
Browse Plan Formulary |
Brand New Day (HMO)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
$2.50 | $5.00 | None | $1,363.55 |
Browse Plan Formulary |
Brand New Day (HMO)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
$2.50 | $5.00 | None | $1,363.55 |
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 |
CareMore Breathe (HMO SNP)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P | $1,271.71 |
Browse Plan Formulary |
CareMore Breathe (HMO SNP)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P | $1,271.71 |
Browse Plan Formulary |
CareMore Connect (HMO SNP)
|
$0.00 |
$320 | to be determined | 5 |
Tier 5 |
25% | n/a | P | $1,271.71 |
Browse Plan Formulary |
CareMore Connect (HMO SNP)
|
$0.00 |
$320 | to be determined | 5 |
Tier 5 |
25% | n/a | P | $1,271.71 |
Browse Plan Formulary |
CareMore ESRD (HMO SNP)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P | $1,271.71 |
Browse Plan Formulary |
CareMore ESRD (HMO SNP)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P | $1,271.71 |
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 |
CareMore Heart (HMO SNP)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P | $1,271.71 |
Browse Plan Formulary |
CareMore Heart (HMO SNP)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P | $1,271.71 |
Browse Plan Formulary |
CareMore Reliance (HMO SNP)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P | $1,271.71 |
Browse Plan Formulary |
CareMore Reliance (HMO SNP)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P | $1,271.71 |
Browse Plan Formulary |
CareMore Touch (HMO SNP)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P | $1,271.71 |
Browse Plan Formulary |
CareMore Touch (HMO SNP)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P | $1,271.71 |
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 |
CareMore Value Plus (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P | $1,272.92 |
Browse Plan Formulary |
CareMore Value Plus (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P | $1,272.92 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P | $1,279.18 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P | $1,279.18 |
Browse Plan Formulary |
Citizens Choice Healthplan (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Tier 4 |
33% | 33% | None | $1,473.47 |
Browse Plan Formulary |
Citizens Choice Healthplan (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Tier 4 |
33% | 33% | None | $1,473.47 |
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 |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
$0.00 | $0.00 | None | $1,366.06 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
$0.00 | $0.00 | None | $1,366.06 |
Browse Plan Formulary |
Health Net Healthy Heart Plan 1 (HMO)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
$5.00 | $10.00 | None | $1,447.73 |
Browse Plan Formulary |
Health Net Healthy Heart Plan 1 (HMO)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
$5.00 | $10.00 | None | $1,447.73 |
Browse Plan Formulary |
Health Net Seniority Plus Ruby Plan 1 (HMO)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
$5.00 | $10.00 | None | $1,447.73 |
Browse Plan Formulary |
Health Net Seniority Plus Ruby Plan 1 (HMO)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
$5.00 | $10.00 | None | $1,447.73 |
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 |
Heart First (HMO SNP)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
25% | n/a | P | $1,263.67 |
Browse Plan Formulary |
Heart First (HMO SNP)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
25% | n/a | P | $1,263.67 |
Browse Plan Formulary |
Humana Gold Plus H0108-011 (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P | $1,147.39 |
Browse Plan Formulary |
Inter Valley Health Plan Service To Seniors (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
25% | n/a | P | $1,279.18 |
Browse Plan Formulary |
Inter Valley Health Plan Total Fit (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P | $1,279.18 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
$8.00 | n/a | None | $1,389.91 |
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 |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
$8.00 | n/a | None | $1,389.91 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
$7.00 | n/a | None | $1,389.91 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
$7.00 | n/a | None | $1,389.91 |
Browse Plan Formulary |
Positive Healthcare Partners (HMO SNP)
|
$0.00 |
$320 | to be determined | 2 |
Tier 2 |
25% | n/a | P | n/a |
Browse Plan Formulary |
Positive Healthcare Partners (HMO SNP)
|
$0.00 |
$320 | to be determined | 2 |
Tier 2 |
25% | n/a | P | n/a |
Browse Plan Formulary |
Salud con Health Net Medicare Advantage (HMO)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
$5.00 | $10.00 | None | $1,447.73 |
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 |
Salud con Health Net Medicare Advantage (HMO)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
$5.00 | $10.00 | None | $1,447.73 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P | $1,263.67 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P | $1,263.67 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P | $1,263.67 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P | $1,263.67 |
Browse Plan Formulary |
StartSmart with CareMore (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P | $1,271.71 |
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 |
StartSmart with CareMore (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P | $1,271.71 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$8.80 |
$0 | to be determined | 2 |
Tier 2 |
$9.00 | n/a | None | $1,389.91 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$8.80 |
$0 | to be determined | 2 |
Tier 2 |
$9.00 | n/a | None | $1,389.91 |
Browse Plan Formulary |
Molina Medicare Options (HMO)
|
$19.00 |
$0 | to be determined | 4 |
Tier 4 |
33% | 33% | P | $1,470.61 |
Browse Plan Formulary |
Health Net Healthy Heart Plan 2 (HMO)
|
$20.00 |
$0 | to be determined | 1 |
Tier 1 |
$5.00 | $10.00 | None | $1,447.73 |
Browse Plan Formulary |
Health Net Healthy Heart Plan 2 (HMO)
|
$20.00 |
$0 | to be determined | 1 |
Tier 1 |
$5.00 | $10.00 | None | $1,447.73 |
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 |
Health Net Seniority Plus Amber I (HMO SNP)
|
$25.80 |
$320 | to be determined | 1 |
Tier 1 |
15% | 15% | None | $1,447.73 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$25.80 |
$320 | to be determined | 1 |
Tier 1 |
15% | 15% | None | $1,447.73 |
Browse Plan Formulary |
Molina Medicare Options (HMO)
|
$29.00 |
$0 | to be determined | 4 |
Tier 4 |
33% | 33% | P | $1,470.61 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$30.10 |
$320 | to be determined | 4 |
Tier 4 |
25% | 25% | P | $1,470.61 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$30.10 |
$320 | to be determined | 4 |
Tier 4 |
25% | 25% | P | $1,470.61 |
Browse Plan Formulary |
Easy Choice Freedom Plan (HMO SNP)
|
$30.80 |
$320 | to be determined | 1 |
Tier 1 |
$0.00 | $0.00 | None | $1,366.06 |
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 |
Easy Choice Freedom Plan (HMO SNP)
|
$30.80 |
$320 | to be determined | 1 |
Tier 1 |
$0.00 | $0.00 | None | $1,366.06 |
Browse Plan Formulary |
L.A. Care Health Plan Medicare Advantage (HMO SNP)
|
$30.80 |
$320 | to be determined | 1 |
Tier 1 |
n/a | n/a | None | $1,352.32 |
Browse Plan Formulary |
L.A. Care Health Plan Medicare Advantage (HMO SNP)
|
$30.80 |
$320 | to be determined | 1 |
Tier 1 |
n/a | n/a | None | $1,352.32 |
Browse Plan Formulary |
Preferred Dual SNP (HMO SNP)
|
$30.80 |
$320 | to be determined | 4 |
Tier 4 |
25% | 25% | P | $1,481.39 |
Browse Plan Formulary |
Preferred Dual SNP (HMO SNP)
|
$30.80 |
$320 | to be determined | 4 |
Tier 4 |
25% | 25% | P | $1,481.39 |
Browse Plan Formulary |
Brand New Day (HMO SNP)
|
$30.90 |
$320 | to be determined | 1 |
Tier 1 |
25% | 25% | None | $1,363.55 |
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 |
Brand New Day (HMO SNP)
|
$30.90 |
$320 | to be determined | 1 |
Tier 1 |
25% | 25% | None | $1,363.55 |
Browse Plan Formulary |
Brand New Day HMO Extra Care (HMO)
|
$30.90 |
$320 | to be determined | 1 |
Tier 1 |
25% | 25% | None | $1,363.55 |
Browse Plan Formulary |
Brand New Day HMO Extra Care (HMO)
|
$30.90 |
$320 | to be determined | 1 |
Tier 1 |
25% | 25% | None | $1,363.55 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO SNP)
|
$30.90 |
$320 | to be determined | 5 |
Tier 5 |
25% | 25% | P | $1,279.18 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO SNP)
|
$30.90 |
$320 | to be determined | 5 |
Tier 5 |
25% | 25% | P | $1,279.18 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$30.90 |
$320 | to be determined | 1 |
Tier 1 |
15% | 15% | None | $1,447.73 |
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 |
Health Net Seniority Plus Amber II (HMO SNP)
|
$30.90 |
$320 | to be determined | 1 |
Tier 1 |
15% | 15% | None | $1,447.73 |
Browse Plan Formulary |
My Choice (HMO-POS)
|
$36.60 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P | $1,263.67 |
Browse Plan Formulary |
Humana Gold Plus H0108-012 (HMO-POS)
|
$39.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P | $1,147.39 |
Browse Plan Formulary |
My Choice (HMO-POS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P | $1,263.67 |
Browse Plan Formulary |