2012 Medicare Advantage Prescription Drug Price Information | ||||||
Blue Medicare Access Standard (Regional PPO) (R5941-003-0) Benefit Details | ||||||
Click on a letter below to view the Blue Medicare Access Standard (Regional PPO) Formulary A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 0-9 | ||||||
AMINOSYN II 15% IV SOLUTION | ||||||
Plan’s average negotiated retail drug price in in Statewide, KY: CMS MA Region 13, includes: IN KY | $297.40* 30-Day Supply $892.19^ 90-Day Supply (calculated) | |||||
Formulary (Drug List) drug tier: | Tier 4 This Tier has No Deductible. | |||||
Does this plan offer any Gap coverage? | ||||||
Does this drug have Gap coverage? | No, this drug IS NOT covered in the gap, but all drugs receive the donut hole discount. | |||||
Drug Usage Management Restrictions: | None | |||||
Formulary (Drug List) Tier Cost-Sharing Details | ||||||
30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing^ |
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Preferred Pharmacy | Standard Pharmacy | Mail- Order** | Preferred Pharmacy | Standard Pharmacy | Mail- Order** | |
Initial $60 Deductible Cost Sharing: | ||||||
33% | 33% | n/a | 33% | 33% | 33% | |
Initial Coverage Phase Cost-Sharing: | ||||||
33% | 33% | n/a | 33% | 33% | 33% | |
Coverage Gap Phase Cost-Sharing Incl. Donut Hole Discount (Generics 14%): | ||||||
86% | 86% | n/a | 86% | 86% | 86% | |
Coverage Gap Phase Cost-Sharing Incl. Donut Hole Discount (Brand 50%): | ||||||
50% | 50% | n/a | 50% | 50% | 50% | |
Catastrophic Coverage Phase Cost-Sharing for Generic & Preferred Multi-Source Drugs: | ||||||
The greater of 5% or $2.60 | The greater of 5% or $2.60 | |||||
Catastrophic Coverage Phase Cost-Sharing for Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | ||||||
The greater of 5% or $6.50 | The greater of 5% or $6.50 | |||||
Your Estimated Cost for Purchases During Each Coverage Phase | ||||||
30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing^ |
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Preferred Pharmacy | Standard Pharmacy | Mail- Order** | Preferred Pharmacy | Standard Pharmacy | Mail- Order** | |
Your Estimated Cost in Deductible Phase: | ||||||
$176.48 | $176.48 | n/a | $334.62^ | $334.62^ | $334.62^ | |
Your Estimated Cost Initial Coverage Phase: | ||||||
$98.14 | $98.14 | n/a | $294.42^ | $294.42^ | $294.42^ | |
Your Estimated Cost in Gap if Drug is Generic (14% discount): | ||||||
$255.76 | $255.76 | n/a | $767.28^ | $767.28^ | $767.28^ | |
Your Estimated Cost in Gap if Drug is Brand-Name (50% discount): | ||||||
$148.70 | $148.70 | n/a | $446.10^ | $446.10^ | $446.10^ | |
Your Estimated Cost in Catastrophic Coverage Phase (Generic): | ||||||
$14.87 | $14.87 | n/a | $44.61 | $44.61 | $44.61 | |
Your Estimated Cost in Catastrophic Coverage (Brand-Name or Non-Preferred Multi-Source Drugs): | ||||||
$14.87 | $14.87 | n/a | $44.61 | $44.61 | $44.61 | |
Tier Cost-Sharing Details and Your Costs with Explanations | ||||||
30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing^ |
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Preferred Pharmacy | Standard Pharmacy | Mail- Order** | Preferred Pharmacy | Standard Pharmacy | Mail- Order** | |
--- If you purchase during the Initial Deductible Phase --- | ||||||
Initial $60 Deductible Cost Sharing: | ||||||
33% | 33% | n/a | 33% | 33% | 33% | |
Your Estimated Cost in Deductible Phase: | ||||||
$176.48 | $176.48 | n/a | $334.62^ | $334.62^ | $334.62^ | |
Explanation for 30-Day Preferred Pharmacy purchase: | ||||||
For a purchase of this drug made during the initial deductible phase, you cross over into other phases of your plan’s coverage (straddle claim). So you pay 100% of the drug cost up to your deductible of $60 and the remaining amount ($297.40-$60) (price - deductible) falls into your initial coverage phase (ICP). For the ICP portion of your coverage, your cost-sharing would be an additional $78.34 or $237.40 x 33% (overage up to your remaining coverage limit ($2,870.00) * cost-sharing). Your estimated cost for a purchase made during the deductible phase would be $176.48 or $98.14 from deductible phase + $78.34 from initial coverage phase. | ||||||
--- If you purchase during the Initial Coverage Phase --- | ||||||
Initial Coverage Phase Cost-Sharing: | ||||||
33% | 33% | n/a | 33% | 33% | 33% | |
Your Estimated Cost Initial Coverage Phase: | ||||||
$98.14 | $98.14 | n/a | $294.42^ | $294.42^ | $294.42^ | |
Explanation for 30-Day Preferred Pharmacy purchase: | ||||||
The cost-sharing for purchases made during the initial coverage phase (ICP) would be $98.14 or ($297.40 x 33%). | ||||||
--- If you purchase during the Coverage Gap Phase (Donut Hole) --- | ||||||
Your Estimated Cost in Gap if Drug is Generic (14% discount): | ||||||
$255.76 | $255.76 | n/a | $767.28^ | $767.28^ | $767.28^ | |
Explanation for 30-Day Preferred Pharmacy purchase: | ||||||
Your cost is the negotiated retail price of $297.40 x 86%. | ||||||
Your Estimated Cost in Gap if Drug is Brand-Name (50% discount): | ||||||
$148.70 | $148.70 | n/a | $446.10^ | $446.10^ | $446.10^ | |
Explanation for 30-Day Preferred Pharmacy purchase: | ||||||
Your costs is the negotiated retail price of $297.40 x 50%. | ||||||
--- If you purchase during the Catastrophic Coverage Phase --- | ||||||
Catastrophic Coverage Phase Cost-Sharing for Generic & Preferred Multi-Source Drugs: | ||||||
The greater of 5% or $2.60 | The greater of 5% or $2.60 | |||||
Your Estimated Cost in Catastrophic Coverage Phase (Generic): | ||||||
$14.87 | $14.87 | n/a | $44.61 | $44.61 | $44.61 | |
Explanation for 30-Day Preferred Pharmacy purchase: | ||||||
In the catastrophic coverage phase, you will pay the greater of 5% of the retail drug price or the minimum cost-share of $2.60. Calculating 5% of $297.40 = $14.87. Since $14.87 is more than $2.60, you would pay $14.87 for this drug at a preferred pharmacy, if it is a generic or preferred multi-source drug. | ||||||
Catastrophic Coverage Phase Cost-Sharing for Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | ||||||
The greater of 5% or $6.50 | The greater of 5% or $6.50 | |||||
Your Estimated Cost in Catastrophic Coverage (Brand-Name or Non-Preferred Multi-Source Drugs): | ||||||
$14.87 | $14.87 | n/a | $44.61 | $44.61 | $44.61 | |
Explanation for 30-Day Preferred Pharmacy purchase: | ||||||
In the catastrophic coverage phase, you will pay the greater of 5% of the retail drug price or the minimum cost-share of $6.50. Calculating 5% of $297.40 = $14.87. Since $14.87 is more than $6.50, you would pay $14.87 for this drug at any pharmacy, if it is not a generic or preferred multi-source drug. | ||||||
Blue Medicare Access Standard (Regional PPO) Average Negotiated Retail Drug Price History | ||||||
30-Day Supply | 90 Day Supply | |||||
April, 2012: | $297.40 | -- | ||||
September, 2010: | $365.44 | -- | ||||
Notes:
*The Medicare drug plan’s average negotiated retail drug price is based on several variables: the medication, the quantity of your prescription, the specific Medicare Part D plan, and the pharmacies in the plan’s service area. In this case, the average of the AMINOSYN II 15% IV SOLUTION prices that the Blue Medicare Access Standard (Regional PPO) has negotiated with each of the retail pharmacies in the plan’s service area (in Statewide, KY: CMS MA Region 13, includes: IN KY). In other words, when you use the Blue Medicare Access Standard (Regional PPO) to purchase AMINOSYN II 15% IV SOLUTION, you may pay slightly more or slightly less than the figures shown in the table above depending on the pharmacy where you fill your prescription and the quantity of your prescription. **The mail-order cost-sharing is the plan’s "preferred" mail-order cost-sharing. ^If the cost-sharing for your 90-day supply is a percentage (co-insurance), your estimated cost shown in the table above is calculated based on the 30-day average retail price multiplied by three (3). Please keep in mind that some plans offer discounts for purchasing a 90-day mail-order supply. For example, if you purchase a 90-day mail-order supply of your medication, you may only pay for a 60-day supply, based on your plan coverage. However, such a plan-specific discount is NOT shown in the table above because this data is not provided to us in a usable format. You can telephone the Medicare prescription drug plan directly for more details. |
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