Xarelto 10mg/1 10 BLISTER PACK in 1 CARTON / 10 TABLET in 1 BLISTER PACK (10 BLISTER PACK in 1 CART ) (NDC: 50458058010)
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 |
3 |
Preferred Brand |
$37.00 | $92.50 | Q:30 /30Days | $276.60 |
Browse Plan Formulary |
Advantra Silver (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35.00 | $87.50 | Q:30 /30Days | $276.03 |
Browse Plan Formulary |
Advantra Silver (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35.00 | $87.50 | Q:30 /30Days | $276.60 |
Browse Plan Formulary |
Bravo-HealthSpring Achieve (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $110.00 | P Q:30 /30Days | $261.96 |
Browse Plan Formulary |
Bravo-HealthSpring Classic (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $110.00 | P Q:30 /30Days | $261.96 |
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 |
2 |
Preferred Brand |
$45.00 | $112.50 | None | $277.18 |
Browse Plan Formulary |
Gateway Health Plan Medicare Assured Select (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | None | $275.34 |
Browse Plan Formulary |
SeniorBlue - Option 3 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:35 /90Days | $271.87 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | P | $273.71 |
Browse Plan Formulary |
HumanaChoice H6900-004 (PPO)
|
$26.00 |
$0 |
Few Generics, Few Brands |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:35 /60Days | $259.89 |
Browse Plan Formulary |
HumanaChoice R5826-081 (Regional PPO)
|
$30.10 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | Q:35 /60Days | $258.96 |
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)
|
$30.40 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
n/a | n/a | P | $273.67 |
Browse Plan Formulary |
HumanaChoice R5826-002 (Regional PPO)
|
$31.70 |
$0 |
Few Generics, Few Brands |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:35 /60Days | $258.96 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$33.70 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | P | $273.96 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (HMO)
|
$36.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:1 /1Days | $278.61 |
Browse Plan Formulary |
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 | None | $275.48 |
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 | None | $275.48 |
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 |
Bravo-HealthSpring Select (HMO SNP)
|
$36.60 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P Q:30 /30Days | $261.96 |
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% | Q:34 /1Days | $273.55 |
Browse Plan Formulary |
Advantra Cares (HMO SNP)
|
$38.80 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | Q:30 /30Days | $275.83 |
Browse Plan Formulary |
Today''s Options Premier Plus 550B (PFFS)
|
$40.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $273.86 |
Browse Plan Formulary |
Geisinger Gold Classic 3 $0 Deductible Rx (HMO)
|
$41.00 |
$0 |
Few Generics |
4 |
Non-Preferred Brand |
$69.00 | $207.00 | Q:34 /1Days | $272.51 |
Browse Plan Formulary |
Advantra Silver Plus (PPO)
|
$43.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35.00 | $87.50 | Q:30 /30Days | $276.60 |
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 |
Gateway Health Plan Medicare Assured Select Plus (HMO SNP)
|
$44.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | None | $275.34 |
Browse Plan Formulary |
Geisinger Gold Preferred 2 $0 Deductible Rx (PPO)
|
$55.00 |
$0 |
Few Generics |
4 |
Non-Preferred Brand |
$69.00 | $207.00 | Q:34 /1Days | $272.32 |
Browse Plan Formulary |
Humana Gold Choice H8145-052 (PFFS)
|
$56.00 |
$0 |
Few Generics, Few Brands |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:35 /60Days | $259.19 |
Browse Plan Formulary |
Freedom Blue PPO ValueRx (PPO)
|
$60.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$45.00 | $112.50 | None | $277.18 |
Browse Plan Formulary |
SeniorBlue - Option 2 (PPO)
|
$63.70 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$44.00 | $132.00 | Q:35 /90Days | $271.86 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$93.00 |
$0 |
Some Generics |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:30 /30Days | $276.60 |
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 |
Geisinger Gold Classic Plus $0 Deductible Rx (HMO-POS)
|
$100.00 |
$0 |
Few Generics |
4 |
Non-Preferred Brand |
$69.00 | $207.00 | Q:34 /1Days | $272.48 |
Browse Plan Formulary |
Today''s Options Premier Plus 150A (PFFS)
|
$105.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $80.00 | None | $273.86 |
Browse Plan Formulary |
SeniorBlue - Option 2 (HMO)
|
$120.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:35 /90Days | $271.87 |
Browse Plan Formulary |
Geisinger Gold Secure 3 (HMO SNP)
|
$123.00 |
$0 |
Few Generics |
4 |
Non-Preferred Brand |
$69.00 | $207.00 | Q:34 /1Days | $272.48 |
Browse Plan Formulary |
HumanaChoice H6900-005 (PPO)
|
$132.00 |
$0 |
Few Generics, Few Brands |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:35 /60Days | $259.76 |
Browse Plan Formulary |
Geisinger Gold Classic 1 $0 Deductible Rx (HMO)
|
$142.00 |
$0 |
Few Generics |
4 |
Non-Preferred Brand |
$69.00 | $207.00 | Q:34 /1Days | $272.48 |
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 Preferred 1 $0 Deductible Rx (PPO)
|
$150.00 |
$0 |
Few Generics |
4 |
Non-Preferred Brand |
$69.00 | $207.00 | Q:34 /1Days | $272.68 |
Browse Plan Formulary |
Freedom Blue PPO Standard (PPO)
|
$165.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$45.00 | $112.50 | None | $277.18 |
Browse Plan Formulary |
SeniorBlue - Option 1 (HMO)
|
$169.30 |
$0 |
Many Generics |
3 |
Preferred Brand |
$38.00 | $114.00 | Q:35 /90Days | $271.87 |
Browse Plan Formulary |
SeniorBlue - Option 1 (PPO)
|
$180.70 |
$0 |
Many Generics |
3 |
Preferred Brand |
$44.00 | $132.00 | Q:35 /90Days | $271.86 |
Browse Plan Formulary |
Freedom Blue PPO Deluxe (PPO)
|
$208.00 |
$0 |
Many Generics |
2 |
Preferred Brand |
$42.00 | $105.00 | None | $277.18 |
Browse Plan Formulary |