MITOMYCIN POWDER FOR INJECTION USP 20MG VIAL (20 MG VIAL) (NDC: 55390025201)
2013 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 Plan 1 (HMO)
|
$0.00 |
$0 |
Some Generics |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $140.94 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 |
Some Generics |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $140.94 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 |
Some Generics |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $140.94 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Premier (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $140.94 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 |
Some Generics |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None | $148.99 |
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 |
Some Generics |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None | $148.99 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
Many Generics |
4 |
Injectable Drugs |
25% | 25% | P | $146.81 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
Many Generics |
4 |
Injectable Drugs |
25% | 25% | P | $146.81 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 |
Many Generics |
4 |
Injectable Drugs |
25% | 25% | P | $146.81 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 |
Many Generics |
4 |
Injectable Drugs |
25% | 25% | P | $146.81 |
Browse Plan Formulary |
Brand New Day (HMO)
|
$0.00 |
$0 |
Many Generics |
1 |
Generic |
$5.00 | $10.00 | P | $145.42 |
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)
|
$0.00 |
$0 |
Many Generics |
1 |
Generic |
$5.00 | $10.00 | P | $145.42 |
Browse Plan Formulary |
CareMore Breathe (HMO SNP)
|
$0.00 |
$0 |
All Generics, All Brands |
2 |
Non-Preferred Generic |
$5.00 | $12.50 | P | $129.67 |
Browse Plan Formulary |
CareMore Breathe (HMO SNP)
|
$0.00 |
$0 |
All Generics, All Brands |
2 |
Non-Preferred Generic |
$5.00 | $12.50 | P | $129.67 |
Browse Plan Formulary |
CareMore Connect (HMO SNP)
|
$0.00 |
$325* |
All Generics, Few Brands |
2* |
Non-Preferred Generic |
$0.00 | $0.00 | P | $129.67 |
Browse Plan Formulary |
CareMore ESRD (HMO SNP)
|
$0.00 |
$0 |
All Generics, All Brands |
2 |
Non-Preferred Generic |
$5.00 | $12.50 | P | $129.67 |
Browse Plan Formulary |
CareMore ESRD (HMO SNP)
|
$0.00 |
$0 |
All Generics, All Brands |
2 |
Non-Preferred Generic |
$5.00 | $12.50 | P | $129.67 |
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 |
All Generics, All Brands |
2 |
Non-Preferred Generic |
$5.00 | $12.50 | P | $129.67 |
Browse Plan Formulary |
CareMore Heart (HMO SNP)
|
$0.00 |
$0 |
All Generics, All Brands |
2 |
Non-Preferred Generic |
$5.00 | $12.50 | P | $129.67 |
Browse Plan Formulary |
CareMore Reliance (HMO SNP)
|
$0.00 |
$0 |
All Generics, All Brands |
2 |
Non-Preferred Generic |
$5.00 | $12.50 | P | $129.67 |
Browse Plan Formulary |
CareMore Reliance (HMO SNP)
|
$0.00 |
$0 |
All Generics, All Brands |
2 |
Non-Preferred Generic |
$5.00 | $12.50 | P | $129.67 |
Browse Plan Formulary |
CareMore Touch (HMO SNP)
|
$0.00 |
$0 |
All Generics, All Brands |
2 |
Non-Preferred Generic |
$5.00 | $12.50 | P | $129.67 |
Browse Plan Formulary |
CareMore Touch (HMO SNP)
|
$0.00 |
$0 |
All Generics, All Brands |
2 |
Non-Preferred Generic |
$5.00 | $12.50 | P | $129.67 |
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 |
All Generics, All Brands |
2 |
Non-Preferred Generic |
$5.00 | $12.50 | P | $129.83 |
Browse Plan Formulary |
CareMore Value Plus (HMO)
|
$0.00 |
$0 |
All Generics, All Brands |
2 |
Non-Preferred Generic |
$5.00 | $12.50 | P | $129.83 |
Browse Plan Formulary |
Citizens Choice Healthplan (HMO)
|
$0.00 |
$0 |
Many Generics |
4 |
Injectable Drugs |
25% | 25% | P | $136.85 |
Browse Plan Formulary |
Citizens Choice Healthplan (HMO)
|
$0.00 |
$0 |
Many Generics |
4 |
Injectable Drugs |
25% | 25% | P | $136.85 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | P | $145.42 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | P | $145.42 |
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 Care (HMO SNP)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | P | $145.42 |
Browse Plan Formulary |
Freedom VIP Care (HMO SNP)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | P | $145.42 |
Browse Plan Formulary |
Freedom VIP Care COPD (HMO SNP)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | P | $145.42 |
Browse Plan Formulary |
Freedom VIP Care COPD (HMO SNP)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | P | $145.42 |
Browse Plan Formulary |
Golden State Medicare Health Plan, Golden (HMO) (HMO)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $141.66 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $147.05 |
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 Gold Select (HMO)
|
$0.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $147.05 |
Browse Plan Formulary |
Health Net Healthy Heart Plan 1 (HMO)
|
$0.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $147.05 |
Browse Plan Formulary |
Health Net Healthy Heart Plan 1 (HMO)
|
$0.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $147.05 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $147.05 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $147.05 |
Browse Plan Formulary |
Health Net Seniority Plus Ruby Plan 1 (HMO)
|
$0.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $147.05 |
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 Ruby Plan 1 (HMO)
|
$0.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $147.05 |
Browse Plan Formulary |
Humana Gold Plus H0108-013 (HMO)
|
$0.00 |
$0 |
Some Generics, Few Brands |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P | $199.38 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$8.00 | $16.00 | None | $139.63 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$8.00 | $16.00 | None | $139.63 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
All Generics, Few Brands |
2 |
Non-Preferred Generic |
$7.00 | $14.00 | None | $139.63 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
All Generics, Few Brands |
2 |
Non-Preferred Generic |
$7.00 | $14.00 | None | $139.63 |
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 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | P | $129.67 |
Browse Plan Formulary |
StartSmart with CareMore (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | P | $129.67 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$11.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $139.63 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$11.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $139.63 |
Browse Plan Formulary |
Health Net Healthy Heart Plan 2 (HMO)
|
$23.90 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $147.05 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$26.90 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $140.94 |
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 |
Humana Gold Plus SNP-DE H0108-016 (HMO SNP)
|
$27.40 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | P | $199.38 |
Browse Plan Formulary |
Brand New Day (HMO SNP)
|
$29.80 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | P | $145.42 |
Browse Plan Formulary |
Brand New Day (HMO SNP)
|
$29.80 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | P | $145.42 |
Browse Plan Formulary |
Brand New Day D SNP (HMO SNP)
|
$29.80 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P | $145.42 |
Browse Plan Formulary |
Brand New Day D SNP (HMO SNP)
|
$29.80 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P | $145.42 |
Browse Plan Formulary |
Brand New Day HMO Extra Care (HMO)
|
$29.80 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | P | $145.42 |
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 Extra Care (HMO)
|
$29.80 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | P | $145.42 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$29.80 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $147.05 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$29.80 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $147.05 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$29.80 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $127.96 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$29.80 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $127.96 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$29.80 |
$325* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Generic |
$0.00 | $0.00 | P | $143.15 |
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 Plus Plan (HMO)
|
$29.90 |
$325* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
25% | 25% | P | $145.42 |
Browse Plan Formulary |
Freedom Plan (HMO SNP)
|
$29.90 |
$325* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | P | $145.42 |
Browse Plan Formulary |
L.A. Care Health Plan Medicare Advantage (HMO SNP)
|
$29.90 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
n/a | n/a | P | $145.46 |
Browse Plan Formulary |
OneCare (HMO SNP)
|
$29.90 |
$0 |
Few Generics |
2 |
Preferred Brand |
$0.00 | n/a | None | $129.40 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$29.90 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $140.94 |
Browse Plan Formulary |
Health Net Healthy Heart Plan 2 (HMO)
|
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $147.05 |
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 |
Humana Gold Plus H0108-014 (HMO-POS)
|
$39.00 |
$0 |
Few Generics, Few Brands |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P | $199.38 |
Browse Plan Formulary |