PENTAM 300 INJ 300MG (10 X 300 MG VIALSD) (NDC: 63323011310)
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 Choice Plan 2 (Regional PPO)
![Email Prescription and/or Health Benefit details for AARP MedicareComplete Choice Plan 2 (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $1,013.19 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
![Email Prescription and/or Health Benefit details for AARP MedicareComplete Plan 1 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Some Generics |
4 |
Non-Preferred Brand |
$89.00 | $257.00 | None | $1,039.42 |
Browse Plan Formulary |
AARP MedicareComplete Plus (HMO-POS)
![Email Prescription and/or Health Benefit details for AARP MedicareComplete Plus (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$89.00 | $257.00 | None | $1,039.42 |
Browse Plan Formulary |
AvMed Medicare Choice (HMO)
![Email Prescription and/or Health Benefit details for AvMed Medicare Choice (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Many Generics, Few Brands |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | None | $1,054.45 |
Browse Plan Formulary |
BlueMedicare HMO (HMO)
![Email Prescription and/or Health Benefit details for BlueMedicare HMO (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
All Generics |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P | $1,033.88 |
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 |
BlueMedicare Regional PPO (Regional PPO)
![Email Prescription and/or Health Benefit details for BlueMedicare Regional PPO (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P | $1,017.39 |
Browse Plan Formulary |
CareDirect (HMO SNP)
![Email Prescription and/or Health Benefit details for CareDirect (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Many Generics, Few Brands |
4 |
Non-Preferred Brand |
$45.00 | $125.00 | P | $1,033.42 |
Browse Plan Formulary |
CareFree (HMO)
![Email Prescription and/or Health Benefit details for CareFree (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Few Generics, Few Brands |
4 |
Non-Preferred Brand |
$45.00 | $125.00 | P | $1,033.42 |
Browse Plan Formulary |
CareHeart (HMO SNP)
![Email Prescription and/or Health Benefit details for CareHeart (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Many Generics, Few Brands |
4 |
Non-Preferred Brand |
$45.00 | $125.00 | P | $1,033.42 |
Browse Plan Formulary |
CareOne (HMO)
![Email Prescription and/or Health Benefit details for CareOne (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Many Generics, Few Brands |
4 |
Non-Preferred Brand |
$45.00 | $125.00 | P | $1,033.42 |
Browse Plan Formulary |
Clear Skies (HMO SNP)
![Email Prescription and/or Health Benefit details for Clear Skies (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
All Generics |
3 |
Non-Preferred Brand |
$40.00 | $120.00 | P | $1,048.16 |
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 Medicare Plan Rx (HMO)
![Email Prescription and/or Health Benefit details for Freedom Medicare Plan Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | P | $1,002.68 |
Browse Plan Formulary |
Freedom Savings Plan Rx (HMO)
![Email Prescription and/or Health Benefit details for Freedom Savings Plan Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | P | $1,002.68 |
Browse Plan Formulary |
Freedom VIP Savings (HMO SNP)
![Email Prescription and/or Health Benefit details for Freedom VIP Savings (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | P | $996.76 |
Browse Plan Formulary |
Freedom VIP Savings COPD (HMO SNP)
![Email Prescription and/or Health Benefit details for Freedom VIP Savings COPD (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | P | $996.76 |
Browse Plan Formulary |
Humana Gold Plus H1036-065C (HMO)
![Email Prescription and/or Health Benefit details for Humana Gold Plus H1036-065C (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Many Generics, Few Brands |
4 |
Non-Preferred Brand |
$45.00 | $125.00 | P | $1,033.42 |
Browse Plan Formulary |
Humana Gold Plus SNP-CVD/CHF H1036-186 (HMO SNP)
![Email Prescription and/or Health Benefit details for Humana Gold Plus SNP-CVD/CHF H1036-186 (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Many Generics, Few Brands |
4 |
Non-Preferred Brand |
$45.00 | $125.00 | P | $1,033.42 |
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 |
Humana Gold Plus SNP-DB H1036-121C (HMO SNP)
![Email Prescription and/or Health Benefit details for Humana Gold Plus SNP-DB H1036-121C (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Many Generics, Few Brands |
4 |
Non-Preferred Brand |
$45.00 | $125.00 | P | $1,033.42 |
Browse Plan Formulary |
Humana Reader''s Digest Healthy Living Plan (Regional PPO)
![Email Prescription and/or Health Benefit details for Humana Reader''s Digest Healthy Living Plan (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Few Generics, Few Brands |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P | $1,016.50 |
Browse Plan Formulary |
Optimum Gold Rewards Plan (HMO-POS)
![Email Prescription and/or Health Benefit details for Optimum Gold Rewards Plan (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | P | $1,002.68 |
Browse Plan Formulary |
Optimum Platinum Plan (HMO-POS)
![Email Prescription and/or Health Benefit details for Optimum Platinum Plan (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | P | $1,002.68 |
Browse Plan Formulary |
Sunrise (HMO)
![Email Prescription and/or Health Benefit details for Sunrise (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
All Generics |
3 |
Non-Preferred Brand |
$40.00 | $120.00 | P | $1,048.16 |
Browse Plan Formulary |
WellCare Dividend (HMO)
![Email Prescription and/or Health Benefit details for WellCare Dividend (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
All Generics |
3 |
Non-Preferred Brand |
$75.00 | $150.00 | P | $1,062.07 |
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 Essential (HMO)
![Email Prescription and/or Health Benefit details for WellCare Essential (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
All Generics |
3 |
Non-Preferred Brand |
$79.00 | $158.00 | P | $1,062.07 |
Browse Plan Formulary |
WellCare Value (HMO-POS)
![Email Prescription and/or Health Benefit details for WellCare Value (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$79.00 | $158.00 | P | $1,062.07 |
Browse Plan Formulary |
Sunny Days (HMO SNP)
![Email Prescription and/or Health Benefit details for Sunny Days (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$4.90 |
$325 |
to be determined |
3 |
Tier 3 |
15% | 15% | P | $1,048.16 |
Browse Plan Formulary |
WellCare Select (HMO-POS SNP)
![Email Prescription and/or Health Benefit details for WellCare Select (HMO-POS SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$8.50 |
$325 |
to be determined |
3 |
Tier 3 |
$95.00 | $190.00 | P | $1,062.07 |
Browse Plan Formulary |
WellCare Liberty (HMO SNP)
![Email Prescription and/or Health Benefit details for WellCare Liberty (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$8.70 |
$325 |
to be determined |
3 |
Tier 3 |
$95.00 | $190.00 | P | $1,062.07 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
![Email Prescription and/or Health Benefit details for WellCare Access (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$12.10 |
$325 |
to be determined |
3 |
Tier 3 |
$95.00 | $190.00 | P | $1,062.07 |
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 H1036-103A (HMO SNP)
![Email Prescription and/or Health Benefit details for Humana Gold Plus SNP-DE H1036-103A (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$12.20 |
$325 |
to be determined |
4 |
Tier 4 |
$95.00 | $275.00 | P | $1,033.42 |
Browse Plan Formulary |
Humana Gold Plus SNP-I H1036-185 (HMO SNP)
![Email Prescription and/or Health Benefit details for Humana Gold Plus SNP-I H1036-185 (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$20.10 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P | $1,033.42 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-162 (HMO SNP)
![Email Prescription and/or Health Benefit details for Humana Gold Plus SNP-DE H1036-162 (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$20.60 |
$325 |
to be determined |
4 |
Tier 4 |
$95.00 | $275.00 | P | $1,033.42 |
Browse Plan Formulary |
Freedom Medi-Medi Full (HMO SNP)
![Email Prescription and/or Health Benefit details for Freedom Medi-Medi Full (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$23.10 |
$325 |
to be determined |
1 |
Tier 1 |
n/a | n/a | P | $996.76 |
Browse Plan Formulary |
CareNeeds PLUS (HMO SNP)
![Email Prescription and/or Health Benefit details for CareNeeds PLUS (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$23.20 |
$325 |
to be determined |
4 |
Tier 4 |
$95.00 | $275.00 | P | $1,033.42 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Nursing Home Plan (PPO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$23.80 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $1,039.42 |
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 |
Sunshine State Health Plan (HMO SNP)
![Email Prescription and/or Health Benefit details for Sunshine State Health Plan (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$24.00 |
$325 |
to be determined |
4 |
Tier 4 |
$95.00 | $95.00 | None | $1,023.91 |
Browse Plan Formulary |
Freedom Medi-Medi Partial (HMO SNP)
![Email Prescription and/or Health Benefit details for Freedom Medi-Medi Partial (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$24.70 |
$325 |
to be determined |
1 |
Tier 1 |
15% | 15% | P | $996.76 |
Browse Plan Formulary |
CareNeeds (HMO SNP)
![Email Prescription and/or Health Benefit details for CareNeeds (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$24.80 |
$325 |
to be determined |
4 |
Tier 4 |
$95.00 | $275.00 | P | $1,033.42 |
Browse Plan Formulary |
Optimum Emerald Full (HMO SNP)
![Email Prescription and/or Health Benefit details for Optimum Emerald Full (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$24.80 |
$325 |
to be determined |
1 |
Tier 1 |
n/a | n/a | P | $1,002.68 |
Browse Plan Formulary |
Optimum Emerald Partial (HMO SNP)
![Email Prescription and/or Health Benefit details for Optimum Emerald Partial (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$24.80 |
$325 |
to be determined |
1 |
Tier 1 |
15% | 15% | P | $1,002.68 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP (Regional PPO SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Dual Complete RP (Regional PPO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$24.80 |
$325 |
to be determined |
4 |
Tier 4 |
15% | 15% | None | $1,013.19 |
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 |
HumanaChoice R5826-005 (Regional PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice R5826-005 (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$28.10 |
$0 |
Few Generics, Few Brands |
4 |
Non-Preferred Brand |
$85.00 | $245.00 | P | $1,016.50 |
Browse Plan Formulary |
HumanaChoice H5415-056 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice H5415-056 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.00 |
$0 |
Few Generics, Few Brands |
3 |
Non-Preferred Brand |
$80.00 | $230.00 | P | $1,033.42 |
Browse Plan Formulary |
Day Break (HMO)
![Email Prescription and/or Health Benefit details for Day Break (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$68.00 |
$0 |
All Generics |
3 |
Non-Preferred Brand |
$60.00 | $180.00 | P | $1,048.16 |
Browse Plan Formulary |
Humana Gold Choice H8145-061 (PFFS)
![Email Prescription and/or Health Benefit details for Humana Gold Choice H8145-061 (PFFS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$102.00 |
$0 |
Few Generics, Few Brands |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P | $1,016.50 |
Browse Plan Formulary |
BlueMedicare PPO (PPO)
![Email Prescription and/or Health Benefit details for BlueMedicare PPO (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$152.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P | $1,017.39 |
Browse Plan Formulary |
HumanaChoice H5415-068 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice H5415-068 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$152.00 |
$0 |
Few Generics, Few Brands |
3 |
Non-Preferred Brand |
$80.00 | $230.00 | P | $1,033.42 |
Browse Plan Formulary |