TRELSTAR MIXJET FOR INJECTION 11.25 MG (VIAL VIALSD) (NDC: 52544018876)
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 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | None | $2,503.49 |
Browse Plan Formulary |
Elderplan Classic: Zero Premium (HMO)
|
$0.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
25% | 25% | None | $2,649.72 |
Browse Plan Formulary |
Touchstone Health Medicare Freedom (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | 33% | None | $2,578.34 |
Browse Plan Formulary |
Touchstone Health Medicare Power (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | 33% | None | $2,578.34 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (Regional PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | None | $2,499.67 |
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 |
VNSNY CHOICE Medicare Enhanced (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | P | $2,491.16 |
Browse Plan Formulary |
WellCare Liberty (HMO SNP)
|
$16.90 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
25% | n/a | P Q:1 /84Days | $2,564.98 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$18.90 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
25% | n/a | P Q:1 /84Days | $2,570.29 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$35.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | None | $2,499.37 |
Browse Plan Formulary |
Touchstone Health Medicare Total (HMO)
|
$38.60 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | 33% | None | $2,578.34 |
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 | $2,598.23 |
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 Preferred (HMO SNP)
|
$40.10 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | P | $2,491.16 |
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 | $2,649.72 |
Browse Plan Formulary |
Touchstone Health Medicare Prestige (HMO SNP)
|
$40.70 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
n/a | n/a | None | $2,578.34 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO SNP)
|
$43.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | P | $2,489.99 |
Browse Plan Formulary |
Healthfirst Maximum Plan (HMO SNP)
|
$43.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
n/a | n/a | P | $2,489.99 |
Browse Plan Formulary |
ArchCare - Inst and IE SNP - All Counties (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | P | $2,507.54 |
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 Complete Plan (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None | $2,561.30 |
Browse Plan Formulary |
CenterLight Direct Total Plan (HMO SNP)
|
$43.20 |
$185 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None | $2,561.30 |
Browse Plan Formulary |
Dual Eligible (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
25% | 25% | P | $2,648.36 |
Browse Plan Formulary |
Dual Eligible (PPO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
25% | 25% | P | $2,648.36 |
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 | $2,649.72 |
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 | $2,649.72 |
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 |
Elderplan Medicaid Advantage (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $2,649.72 |
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 | $2,649.72 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO SNP)
|
$43.20 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | P | $2,501.59 |
Browse Plan Formulary |
Fidelis Long Term Care Advantage (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $2,501.59 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
|
$43.20 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | P | $2,501.59 |
Browse Plan Formulary |
PPO II (PPO)
|
$52.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$35.00 | $70.00 | P | $2,648.33 |
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 |
Aetna Medicare Value Plan (HMO)
|
$78.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P | $2,564.17 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Maximum (HMO SNP)
|
$78.50 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
n/a | n/a | P | $2,491.16 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO SNP)
|
$95.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
n/a | n/a | P | $2,491.16 |
Browse Plan Formulary |
PPO III (PPO)
|
$112.50 |
$0 |
All Generics |
2 |
Preferred Brand |
$35.00 | $70.00 | P | $2,648.33 |
Browse Plan Formulary |
VIP Essential (HMO)
|
$126.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$35.00 | $70.00 | P | $2,648.60 |
Browse Plan Formulary |
VIP Essential (HMO)
|
$126.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$35.00 | $70.00 | P | $2,648.32 |
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 Essential (HMO)
|
$126.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$35.00 | $70.00 | P | $2,648.60 |
Browse Plan Formulary |
VIP (HMO)
|
$141.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$35.00 | $70.00 | P | $2,648.60 |
Browse Plan Formulary |
VIP (HMO)
|
$141.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$35.00 | $70.00 | P | $2,648.32 |
Browse Plan Formulary |
VIP (HMO)
|
$141.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$35.00 | $70.00 | P | $2,648.60 |
Browse Plan Formulary |
PPO High Option (PPO)
|
$218.50 |
$0 |
All Generics |
2 |
Preferred Brand |
$35.00 | $70.00 | P | $2,648.33 |
Browse Plan Formulary |
VIP High Option (HMO)
|
$309.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$35.00 | $70.00 | P | $2,648.60 |
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 High Option (HMO)
|
$309.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$35.00 | $70.00 | P | $2,648.32 |
Browse Plan Formulary |
VIP High Option (HMO)
|
$309.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$35.00 | $70.00 | P | $2,648.60 |
Browse Plan Formulary |