THIOTEPA POWDER FOR INJECTION 15MG/VIL 1 VIAL SINGLE DOSE CRTN (1 VIAL SINGLE DOSE CRTN) (NDC: 55390003010)
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)
![Email Prescription and/or Health Benefit details for AARP MedicareComplete Mosaic (HMO)](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 |
$92.00 | $266.00 | None | $590.64 |
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 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$92.00 | $266.00 | None | $590.64 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
![Email Prescription and/or Health Benefit details for AARP MedicareComplete Plan 2 (HMO)](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 | $590.64 |
Browse Plan Formulary |
Access Medicare Gold (HMO)
![Email Prescription and/or Health Benefit details for Access Medicare Gold (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$0.00 | $0.00 | None | $607.40 |
Browse Plan Formulary |
Easy Choice Diamond Rewards (HMO SNP)
![Email Prescription and/or Health Benefit details for Easy Choice Diamond Rewards (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 | $567.85 |
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 Diamond Rewards COPD (HMO SNP)
![Email Prescription and/or Health Benefit details for Easy Choice Diamond Rewards 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 | $567.85 |
Browse Plan Formulary |
Easy Choice Rewards (HMO)
![Email Prescription and/or Health Benefit details for Easy Choice Rewards (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 | $567.85 |
Browse Plan Formulary |
Easy Choice Value (HMO)
![Email Prescription and/or Health Benefit details for Easy Choice Value (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | P | $567.85 |
Browse Plan Formulary |
Elderplan Classic: Zero Premium (HMO)
![Email Prescription and/or Health Benefit details for Elderplan Classic: Zero Premium (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$4.00 | $10.00 | P | $589.26 |
Browse Plan Formulary |
Fidelis Medicare $0 Premium (HMO)
![Email Prescription and/or Health Benefit details for Fidelis Medicare $0 Premium (HMO)](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 |
$75.00 | $150.00 | P | $658.82 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
![Email Prescription and/or Health Benefit details for Healthfirst 65 Plus Plan (HMO)](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 |
$80.00 | $200.00 | P | $642.40 |
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 |
Healthfirst Jade Benefits Plan (HMO)
![Email Prescription and/or Health Benefit details for Healthfirst Jade Benefits Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Many Generics, Few Brands |
3 |
Non-Preferred Brand |
$80.00 | $200.00 | P | $642.40 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (Regional PPO)
![Email Prescription and/or Health Benefit details for UnitedHealthcare MedicareComplete Choice (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 | $590.64 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Enhanced (HMO)
![Email Prescription and/or Health Benefit details for VNSNY CHOICE Medicare Enhanced (HMO)](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 |
$90.00 | $225.00 | P | $640.19 |
Browse Plan Formulary |
Healthfirst Increased Benefits Plan (HMO)
![Email Prescription and/or Health Benefit details for Healthfirst Increased Benefits Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$35.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | P | $642.40 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Nursing Home Plan (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$35.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $590.64 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Preferred (HMO SNP)
![Email Prescription and/or Health Benefit details for VNSNY CHOICE Medicare Preferred (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$40.10 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | P | $640.19 |
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 |
Elderplan Advantage For Nursing Home Residents (HMO SNP)
![Email Prescription and/or Health Benefit details for Elderplan Advantage For Nursing Home Residents (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$40.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | P | $589.26 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Dual Complete (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$41.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
n/a | n/a | None | $590.64 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete LP (HMO SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Dual Complete LP (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $590.64 |
Browse Plan Formulary |
Healthfirst AssuredCare (HMO SNP)
![Email Prescription and/or Health Benefit details for Healthfirst AssuredCare (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$43.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | P | $642.40 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO SNP)
![Email Prescription and/or Health Benefit details for Healthfirst CompleteCare (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$43.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
n/a | n/a | P | $642.40 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO SNP)
![Email Prescription and/or Health Benefit details for Healthfirst Life Improvement Plan (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$43.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | P | $642.40 |
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 |
Healthfirst Maximum Plan (HMO SNP)
![Email Prescription and/or Health Benefit details for Healthfirst Maximum Plan (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$43.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
n/a | n/a | P | $642.40 |
Browse Plan Formulary |
Access Medicare Pearl (HMO SNP)
![Email Prescription and/or Health Benefit details for Access Medicare Pearl (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $607.40 |
Browse Plan Formulary |
Access Medicare Platinum (HMO)
![Email Prescription and/or Health Benefit details for Access Medicare Platinum (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $607.40 |
Browse Plan Formulary |
Access Medicare Silver (HMO SNP)
![Email Prescription and/or Health Benefit details for Access Medicare Silver (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $607.40 |
Browse Plan Formulary |
ArchCare - Inst and IE SNP - All Counties (HMO SNP)
![Email Prescription and/or Health Benefit details for ArchCare - Inst and IE SNP - All Counties (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | P | $654.10 |
Browse Plan Formulary |
CenterLight Direct Complete Plan (HMO SNP)
![Email Prescription and/or Health Benefit details for CenterLight Direct Complete Plan (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$43.20 |
$325* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Generic |
$7.25 | $21.75 | None | $623.08 |
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 |
CenterLight Direct Total Plan (HMO SNP)
![Email Prescription and/or Health Benefit details for CenterLight Direct Total Plan (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$43.20 |
$185* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Generic |
$8.00 | $24.00 | None | $623.08 |
Browse Plan Formulary |
Elderplan Extra Help (HMO)
![Email Prescription and/or Health Benefit details for Elderplan Extra Help (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | P | $589.26 |
Browse Plan Formulary |
Elderplan For Medicaid Beneficiaries (HMO SNP)
![Email Prescription and/or Health Benefit details for Elderplan For Medicaid Beneficiaries (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P | $589.26 |
Browse Plan Formulary |
Elderplan Medicaid Advantage (HMO SNP)
![Email Prescription and/or Health Benefit details for Elderplan Medicaid Advantage (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P | $589.26 |
Browse Plan Formulary |
Elderplan Plus Long Term Care (HMO SNP)
![Email Prescription and/or Health Benefit details for Elderplan Plus Long Term Care (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P | $589.26 |
Browse Plan Formulary |
Fidelis Dual Advantage (HMO SNP)
![Email Prescription and/or Health Benefit details for Fidelis Dual Advantage (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P | $658.82 |
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 Flex (HMO SNP)
![Email Prescription and/or Health Benefit details for Fidelis Dual Advantage Flex (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$43.20 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | P | $658.82 |
Browse Plan Formulary |
Fidelis Long Term Care Advantage (HMO SNP)
![Email Prescription and/or Health Benefit details for Fidelis Long Term Care Advantage (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | P | $658.82 |
Browse Plan Formulary |
Fidelis Medicaid Advantage Plus (HMO SNP)
![Email Prescription and/or Health Benefit details for Fidelis Medicaid Advantage Plus (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$91.00 | $182.00 | P | $658.82 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
![Email Prescription and/or Health Benefit details for Fidelis Medicare Advantage Flex (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$43.20 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | P | $658.82 |
Browse Plan Formulary |
Senior Whole Health of New York (HMO SNP)
![Email Prescription and/or Health Benefit details for Senior Whole Health of New York (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$43.20 |
$325* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Generic |
$0.00 | $0.00 | None | $609.68 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Value Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$50.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None | $621.53 |
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 Maximum (HMO SNP)
![Email Prescription and/or Health Benefit details for VNSNY CHOICE Medicare Maximum (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$78.50 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
n/a | n/a | P | $640.19 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (HMO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Standard Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$80.00 |
$0 |
Some Generics |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None | $621.53 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Standard Plan (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$85.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None | $621.53 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO SNP)
![Email Prescription and/or Health Benefit details for VNSNY CHOICE Total (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$95.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
n/a | n/a | P | $640.19 |
Browse Plan Formulary |