OXYCODONE HYDROCHLORIDE 10mg/1 100 TABLET BOTTLE (100 TABLET in 1 BOTTLE ) (NDC: 10702005601)
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 Mosaic (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$4.00 | $8.00 | None | $42.55 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$6.00 | $12.00 | None | $42.55 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None | $42.55 |
Browse Plan Formulary |
Access Medicare Gold (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $39.17 |
Browse Plan Formulary |
Amerivantage Balance + Rx (HMO)
|
$0.00 |
$0 |
Some Generics |
2 |
Non-Preferred Generic |
$4.00 | $8.00 | Q:180 /30Days | $57.90 |
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 |
Amerivantage Classic Choice + Rx Plan (HMO-POS)
|
$0.00 |
$0 |
Some Generics |
2 |
Non-Preferred Generic |
$3.00 | $6.00 | Q:180 /30Days | $57.90 |
Browse Plan Formulary |
Easy Choice Diamond Rewards (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$20.00 | $40.00 | Q:360 /30Days | $40.04 |
Browse Plan Formulary |
Easy Choice Diamond Rewards COPD (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$20.00 | $40.00 | Q:360 /30Days | $40.04 |
Browse Plan Formulary |
Easy Choice Rewards (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$39.00 | $78.00 | Q:360 /30Days | $40.04 |
Browse Plan Formulary |
Easy Choice Value (HMO)
|
$0.00 |
$0 |
Many Generics |
2 |
Preferred Brand |
$20.00 | $40.00 | Q:360 /30Days | $40.04 |
Browse Plan Formulary |
Elderplan Classic: Zero Premium (HMO)
|
$0.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$4.00 | $10.00 | None | $42.27 |
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 |
Empire MediBlue Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | Q:810 /30Days | $37.82 |
Browse Plan Formulary |
Fidelis Medicare $0 Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | Q:180 /30Days | $57.40 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $57.33 |
Browse Plan Formulary |
Healthfirst Jade Benefits Plan (HMO)
|
$0.00 |
$0 |
Many Generics, Few Brands |
1 |
Generic |
$0.00 | $0.00 | Q:180 /30Days | $57.33 |
Browse Plan Formulary |
PPO II (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$5.00 | $10.00 | None | $35.72 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (Regional PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$6.00 | $12.00 | None | $41.73 |
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 |
VIP (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$5.00 | $10.00 | None | $35.72 |
Browse Plan Formulary |
VIP (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$5.00 | $10.00 | None | $35.72 |
Browse Plan Formulary |
VIP (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$5.00 | $10.00 | None | $35.72 |
Browse Plan Formulary |
VIP Essential (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$5.00 | $10.00 | None | $35.72 |
Browse Plan Formulary |
VIP Essential (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$5.00 | $10.00 | None | $35.72 |
Browse Plan Formulary |
VIP Essential (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$5.00 | $10.00 | None | $35.72 |
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 |
VNSNY CHOICE Medicare Enhanced (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$4.00 | $10.00 | Q:180 /30Days | $57.32 |
Browse Plan Formulary |
WellCare Choice (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$0.00 | $0.00 | Q:248 /31Days | $62.70 |
Browse Plan Formulary |
WellCare Rx (HMO)
|
$1.60 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$8.00 | $0.00 | Q:248 /31Days | $62.70 |
Browse Plan Formulary |
WellCare Liberty (HMO SNP)
|
$20.60 |
$325* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Generic |
$0.00 | $0.00 | Q:248 /31Days | $63.07 |
Browse Plan Formulary |
WellCare Advocate Complete (HMO SNP)
|
$28.40 |
$325* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Generic |
$0.00 | $0.00 | Q:248 /31Days | $62.02 |
Browse Plan Formulary |
MetroPlus Platinum (HMO)
|
$34.70 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:180 /30Days | $57.33 |
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 |
Healthfirst Increased Benefits Plan (HMO)
|
$35.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:180 /30Days | $57.33 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$35.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $42.14 |
Browse Plan Formulary |
HHH Choices Gold (HMO SNP)
|
$39.70 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $42.14 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Preferred (HMO SNP)
|
$40.10 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | Q:180 /30Days | $57.32 |
Browse Plan Formulary |
Elderplan Advantage For Nursing Home Residents (HMO SNP)
|
$40.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $42.27 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$40.40 |
$325* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Generic |
$0.00 | $0.00 | Q:248 /31Days | $62.70 |
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 |
UnitedHealthcare Dual Complete (HMO SNP)
|
$41.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
n/a | n/a | None | $42.61 |
Browse Plan Formulary |
GuildNet Health Advantage (HMO-POS SNP)
|
$41.60 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $35.72 |
Browse Plan Formulary |
MetroPlus Advantage Plan (HMO SNP)
|
$41.70 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:180 /30Days | $57.33 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete LP (HMO SNP)
|
$42.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $42.55 |
Browse Plan Formulary |
Healthfirst AssuredCare (HMO SNP)
|
$43.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:180 /30Days | $57.33 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO SNP)
|
$43.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
n/a | n/a | Q:180 /30Days | $57.33 |
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 |
Healthfirst Life Improvement Plan (HMO SNP)
|
$43.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:180 /30Days | $57.33 |
Browse Plan Formulary |
Healthfirst Maximum Plan (HMO SNP)
|
$43.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
n/a | n/a | Q:180 /30Days | $57.33 |
Browse Plan Formulary |
MetroPlus Select Plan (HMO SNP)
|
$43.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
n/a | n/a | Q:180 /30Days | $57.33 |
Browse Plan Formulary |
Access Medicare Pearl (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:180 /30Days | $39.17 |
Browse Plan Formulary |
Access Medicare Platinum (HMO)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:180 /30Days | $39.17 |
Browse Plan Formulary |
Access Medicare Silver (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:180 /30Days | $39.17 |
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 |
Affinity Medicare Solutions (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:180 /30Days | $57.31 |
Browse Plan Formulary |
Affinity Medicare Ultimate (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
0% | 0% | Q:180 /30Days | $57.31 |
Browse Plan Formulary |
Amerivantage Specialty + Rx (HMO SNP)
|
$43.20 |
$325* |
Many Generics, Few Brands |
2* |
Non-Preferred Generic |
$0.00 | $0.00 | Q:180 /30Days | $57.90 |
Browse Plan Formulary |
ArchCare - Inst and IE SNP - All Counties (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:180 /30Days | $57.61 |
Browse Plan Formulary |
CenterLight Direct Complete Plan (HMO SNP)
|
$43.20 |
$325* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Generic |
$7.25 | $21.75 | Q:540 /90Days | $56.35 |
Browse Plan Formulary |
CenterLight Direct Total Plan (HMO SNP)
|
$43.20 |
$185* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Generic |
$8.00 | $24.00 | Q:540 /90Days | $56.35 |
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 |
Dual Eligible (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$4.00 | $8.00 | None | $35.72 |
Browse Plan Formulary |
Dual Eligible (PPO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$4.00 | $8.00 | None | $35.72 |
Browse Plan Formulary |
Elderplan Extra Help (HMO)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $42.27 |
Browse Plan Formulary |
Elderplan For Medicaid Beneficiaries (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $42.27 |
Browse Plan Formulary |
Elderplan Medicaid Advantage (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $42.27 |
Browse Plan Formulary |
Elderplan Plus Long Term Care (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $42.27 |
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 |
Fidelis Dual Advantage (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | Q:180 /30Days | $57.40 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO SNP)
|
$43.20 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | Q:180 /30Days | $57.68 |
Browse Plan Formulary |
Fidelis Long Term Care Advantage (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | Q:180 /30Days | $57.68 |
Browse Plan Formulary |
Fidelis Medicaid Advantage Plus (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | Q:180 /30Days | $57.36 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
|
$43.20 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | Q:180 /30Days | $57.68 |
Browse Plan Formulary |
GuildNet Gold (HMO-POS SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
n/a | n/a | None | $35.72 |
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 |
Senior Whole Health of New York (HMO SNP)
|
$43.20 |
$325* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Generic |
$0.00 | $0.00 | None | $46.06 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$50.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$6.00 | $12.00 | Q:6 /1Days | $59.73 |
Browse Plan Formulary |
PPO III (PPO)
|
$54.50 |
$0 |
All Generics |
1 |
Preferred Generic |
$5.00 | $10.00 | None | $35.72 |
Browse Plan Formulary |
MetroPlus Medicare Partnership in Care Plan (HMO SNP)
|
$67.10 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:180 /30Days | $57.33 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Maximum (HMO SNP)
|
$78.50 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
n/a | n/a | Q:180 /30Days | $57.32 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (HMO)
|
$80.00 |
$0 |
Some Generics |
1 |
Preferred Generic |
$6.00 | $12.00 | Q:6 /1Days | $59.73 |
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 |
Aetna Medicare Standard Plan (PPO)
|
$85.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$6.00 | $12.00 | Q:6 /1Days | $58.94 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO SNP)
|
$95.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
n/a | n/a | Q:180 /30Days | $57.32 |
Browse Plan Formulary |
PPO High Option (PPO)
|
$132.50 |
$0 |
All Generics |
1 |
Preferred Generic |
$5.00 | $10.00 | None | $35.72 |
Browse Plan Formulary |
VIP High Option (HMO)
|
$157.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$5.00 | $10.00 | None | $35.72 |
Browse Plan Formulary |
VIP High Option (HMO)
|
$157.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$5.00 | $10.00 | None | $35.72 |
Browse Plan Formulary |
VIP High Option (HMO)
|
$157.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$5.00 | $10.00 | None | $35.72 |
Browse Plan Formulary |