POMALYST 3 MG CAPSULE (NDC: 59572050300)
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 |
Advantra Elite (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:21 /28Days | $15,723.90 |
Browse Plan Formulary |
Advantra Silver (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:21 /28Days | $15,723.90 |
Browse Plan Formulary |
Advantra Silver (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:21 /28Days | $15,723.90 |
Browse Plan Formulary |
Bravo-HealthSpring Achieve (HMO SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | 33% | P Q:21 /28Days | $15,056.70 |
Browse Plan Formulary |
Bravo-HealthSpring Classic (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | 33% | P Q:21 /28Days | $15,056.70 |
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 |
Freedom Blue PPO HD Rx (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Specialty Tier |
33% | 33% | P | $15,934.40 |
Browse Plan Formulary |
Gateway Health Plan Medicare Assured Select (HMO SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | 33% | P | $15,276.80 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | 33% | P | $15,689.70 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | 33% | P | $15,689.70 |
Browse Plan Formulary |
HumanaChoice H6900-004 (PPO)
|
$26.00 |
$0 | Few Generics, Few Brands | 5 |
Specialty Tier |
33% | n/a | P Q:21 /28Days | $15,596.80 |
Browse Plan Formulary |
Today''s Options Advantage Plus 550B (PPO)
|
$28.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
29% | n/a | P | $16,191.40 |
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 R5826-081 (Regional PPO)
|
$30.10 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | P Q:21 /28Days | $15,596.80 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$30.40 |
$325 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
n/a | n/a | P | $15,689.70 |
Browse Plan Formulary |
HumanaChoice R5826-002 (Regional PPO)
|
$31.70 |
$0 | Few Generics, Few Brands | 5 |
Specialty Tier |
33% | n/a | P Q:21 /28Days | $15,596.80 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$33.70 |
$325 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | P | $15,689.70 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (HMO)
|
$36.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | 33% | P | $16,276.80 |
Browse Plan Formulary |
AmeriHealth VIP Care (HMO SNP)
|
$36.50 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | P | $15,222.00 |
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 |
Gateway Health Plan Medicare Assured 3 (HMO SNP)
|
$36.50 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | n/a | P | $15,398.10 |
Browse Plan Formulary |
Gateway Health Plan Medicare Assured (HMO SNP)
|
$36.50 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
n/a | n/a | P | $15,398.10 |
Browse Plan Formulary |
Bravo-HealthSpring Select (HMO SNP)
|
$36.60 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | P Q:21 /28Days | $15,056.70 |
Browse Plan Formulary |
Geisinger Gold Secure 1 (HMO SNP)
|
$38.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | P Q:21 /28Days | $15,575.50 |
Browse Plan Formulary |
Advantra Cares (HMO SNP)
|
$38.80 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | P Q:21 /28Days | $15,723.90 |
Browse Plan Formulary |
Today''s Options Premier Plus 550B (PFFS)
|
$40.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
29% | n/a | P | $16,191.40 |
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 |
Geisinger Gold Classic 3 $0 Deductible Rx (HMO)
|
$41.00 |
$0 | Few Generics | 5 |
Specialty Tier |
33% | n/a | P Q:21 /28Days | $15,575.50 |
Browse Plan Formulary |
Advantra Silver Plus (PPO)
|
$43.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:21 /28Days | $15,723.90 |
Browse Plan Formulary |
Gateway Health Plan Medicare Assured Select Plus (HMO SNP)
|
$44.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | 33% | P | $15,276.80 |
Browse Plan Formulary |
Geisinger Gold Preferred 2 $0 Deductible Rx (PPO)
|
$55.00 |
$0 | Few Generics | 5 |
Specialty Tier |
33% | n/a | P Q:21 /28Days | $15,575.50 |
Browse Plan Formulary |
Humana Gold Choice H8145-052 (PFFS)
|
$56.00 |
$0 | Few Generics, Few Brands | 5 |
Specialty Tier |
33% | n/a | P Q:21 /28Days | $15,596.80 |
Browse Plan Formulary |
Freedom Blue PPO ValueRx (PPO)
|
$60.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Specialty Tier |
33% | 33% | P | $15,934.40 |
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 |
SeniorBlue - Option 2 (PPO)
|
$63.70 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $15,979.40 |
Browse Plan Formulary |
Geisinger Gold Preferred 1 $0 Deductible Rx (PPO)
|
$74.00 |
$0 | Few Generics | 5 |
Specialty Tier |
33% | n/a | P Q:21 /28Days | $15,575.50 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$93.00 |
$0 | Some Generics | 5 |
Specialty Tier |
33% | n/a | P Q:21 /28Days | $15,723.90 |
Browse Plan Formulary |
Geisinger Gold Classic Plus $0 Deductible Rx (HMO-POS)
|
$100.00 |
$0 | Few Generics | 5 |
Specialty Tier |
33% | n/a | P Q:21 /28Days | $15,575.50 |
Browse Plan Formulary |
Today''s Options Advantage Plus 150A (PPO)
|
$105.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $16,191.40 |
Browse Plan Formulary |
Today''s Options Premier Plus 150A (PFFS)
|
$105.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $16,191.40 |
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 Premier Plan (PPO)
|
$120.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | 33% | P | $16,276.80 |
Browse Plan Formulary |
Geisinger Gold Secure 3 (HMO SNP)
|
$123.00 |
$0 | Few Generics | 5 |
Specialty Tier |
33% | n/a | P Q:21 /28Days | $15,575.50 |
Browse Plan Formulary |
HumanaChoice H6900-005 (PPO)
|
$132.00 |
$0 | Few Generics, Few Brands | 5 |
Specialty Tier |
33% | n/a | P Q:21 /28Days | $15,596.80 |
Browse Plan Formulary |
Geisinger Gold Classic 1 $0 Deductible Rx (HMO)
|
$142.00 |
$0 | Few Generics | 5 |
Specialty Tier |
33% | n/a | P Q:21 /28Days | $15,575.50 |
Browse Plan Formulary |
Freedom Blue PPO Standard (PPO)
|
$165.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Specialty Tier |
33% | 33% | P | $15,934.40 |
Browse Plan Formulary |
SeniorBlue - Option 1 (PPO)
|
$180.70 |
$0 | Many Generics | 5 |
Specialty Tier |
33% | n/a | P | $15,979.40 |
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 Blue PPO Deluxe (PPO)
|
$208.00 |
$0 | Many Generics | 4 |
Specialty Tier |
33% | 33% | P | $15,934.40 |
Browse Plan Formulary |