BLEOMYCIN SULFATE 30UNITS VIA (1 X 20ML PKG) (NDC: 00703315501)
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)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $125.00 | P | $89.85 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
|
$0.00 |
$0 | Some Generics | 3 |
Preferred Brand |
$30.00 | $80.00 | P | $89.85 |
Browse Plan Formulary |
AARP MedicareComplete Plus (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$30.00 | $80.00 | P | $89.85 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$33.00 | $66.00 | P | $95.30 |
Browse Plan Formulary |
Amerivantage Classic+ Rx Plan (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$4.00 | $8.00 | P | $94.74 |
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 |
AvMed Medicare Choice (HMO)
|
$0.00 |
$0 | Many Generics, Few Brands | 2 |
Non-Preferred Generic |
$0.00 | $0.00 | None | $93.61 |
Browse Plan Formulary |
BlueMedicare HMO (HMO)
|
$0.00 |
$0 | All Generics | 2 |
Non-Preferred Generic |
$0.00 | $0.00 | P | $82.63 |
Browse Plan Formulary |
BlueMedicare Regional PPO (Regional PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $15.00 | P | $82.63 |
Browse Plan Formulary |
CareDirect (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 1 |
Preferred Generic |
$0.00 | $0.00 | P | $127.00 |
Browse Plan Formulary |
CareFree (HMO)
|
$0.00 |
$0 | Few Generics, Few Brands | 1 |
Preferred Generic |
$0.00 | $0.00 | P | $127.00 |
Browse Plan Formulary |
CareHeart (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 1 |
Preferred Generic |
$0.00 | $0.00 | P | $127.00 |
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 |
CareOne (HMO)
|
$0.00 |
$0 | Many Generics, Few Brands | 1 |
Preferred Generic |
$0.00 | $0.00 | P | $127.00 |
Browse Plan Formulary |
Clear Skies (HMO SNP)
|
$0.00 |
$0 | All Generics | 3 |
Non-Preferred Brand |
$40.00 | $120.00 | P | $83.17 |
Browse Plan Formulary |
Coventry Summit Ideal (HMO-POS)
|
$0.00 |
$0 | Many Generics | 3 |
Non-Preferred Brand |
$40.00 | $120.00 | P | $92.35 |
Browse Plan Formulary |
Coventry Summit Plus (HMO)
|
$0.00 |
$0 | Many Generics | 3 |
Non-Preferred Brand |
$70.00 | $210.00 | P | $92.35 |
Browse Plan Formulary |
Coventry Summit Select (HMO-POS)
|
$0.00 |
$0 | Many Generics | 3 |
Non-Preferred Brand |
$70.00 | $210.00 | P | $92.35 |
Browse Plan Formulary |
Coventry Vista Ideal (HMO)
|
$0.00 |
$0 | Many Generics | 3 |
Non-Preferred Brand |
$75.00 | $225.00 | P | $92.35 |
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 |
Coventry Vista Prime (HMO)
|
$0.00 |
$0 | Many Generics | 3 |
Non-Preferred Brand |
$50.00 | $150.00 | P | $92.35 |
Browse Plan Formulary |
Freedom Medicare Plan Rx (HMO)
|
$0.00 |
$0 | Many Generics | 1 |
Preferred Generic |
$0.00 | $0.00 | P | $86.49 |
Browse Plan Formulary |
Freedom Savings Plan Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | P | $86.49 |
Browse Plan Formulary |
Freedom VIP Savings (HMO SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | P | $86.49 |
Browse Plan Formulary |
Freedom VIP Savings COPD (HMO SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | P | $86.49 |
Browse Plan Formulary |
Humana Gold Plus H1036-065C (HMO)
|
$0.00 |
$0 | Many Generics, Few Brands | 1 |
Preferred Generic |
$0.00 | $0.00 | P | $127.00 |
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 |
Humana Gold Plus SNP-CVD/CHF H1036-186 (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 1 |
Preferred Generic |
$0.00 | $0.00 | P | $127.00 |
Browse Plan Formulary |
Humana Gold Plus SNP-DB H1036-121C (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 1 |
Preferred Generic |
$0.00 | $0.00 | P | $127.00 |
Browse Plan Formulary |
Humana Reader''s Digest Healthy Living Plan (Regional PPO)
|
$0.00 |
$0 | Few Generics, Few Brands | 3 |
Preferred Brand |
$45.00 | $125.00 | P | $127.00 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax (HMO)
|
$0.00 |
$0 | Many Generics | 1 |
Generic |
$0.00 | n/a | P | $96.30 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax Value RX (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$0.00 | n/a | P | $96.30 |
Browse Plan Formulary |
Optimum Gold Rewards Plan (HMO-POS)
|
$0.00 |
$0 | Many Generics | 1 |
Preferred Generic |
$0.00 | $0.00 | P | $86.49 |
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 |
Optimum Platinum Plan (HMO-POS)
|
$0.00 |
$0 | Many Generics | 1 |
Preferred Generic |
$0.00 | $0.00 | P | $86.49 |
Browse Plan Formulary |
Positive Healthcare Partners (HMO SNP)
|
$0.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
25% | n/a | P | $87.36 |
Browse Plan Formulary |
PUP EASY (HMO)
|
$0.00 |
$0 | Many Generics | 3 |
Non-Preferred Brand |
$45.00 | $115.00 | P | $90.30 |
Browse Plan Formulary |
PUP REWARDS (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$90.00 | $270.00 | P | $90.30 |
Browse Plan Formulary |
SunPlus Advantage Plan (HMO)
|
$0.00 |
$0 | All Generics, All Brands | 2 |
Non-Preferred Generic |
$0.00 | n/a | None | $87.48 |
Browse Plan Formulary |
SunPlus Diabetes Special Needs Plan (HMO SNP)
|
$0.00 |
$0 | All Generics, All Brands | 2 |
Non-Preferred Generic |
$0.00 | n/a | None | $87.48 |
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 |
Sunrise (HMO)
|
$0.00 |
$0 | All Generics | 3 |
Non-Preferred Brand |
$40.00 | $120.00 | P | $83.17 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$0 | All Generics | 1 |
Generic |
$3.00 | $0.00 | P | $91.32 |
Browse Plan Formulary |
WellCare Essential (HMO)
|
$0.00 |
$0 | All Generics | 1 |
Generic |
$0.00 | $0.00 | P | $91.32 |
Browse Plan Formulary |
WellCare Value (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$0.00 | $0.00 | P | $91.32 |
Browse Plan Formulary |
PUP EXTRA (HMO SNP)
|
$4.90 |
$0 | to be determined | 3 |
Tier 3 |
$0.00 | $0.00 | P | $90.30 |
Browse Plan Formulary |
Sunny Days (HMO SNP)
|
$4.90 |
$325 | to be determined | 3 |
Tier 3 |
15% | 15% | P | $83.17 |
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 Select (HMO-POS SNP)
|
$8.50 |
$325* | to be determined | 1* |
Tier 1 |
$0.00 | $0.00 | P | $91.32 |
Browse Plan Formulary |
WellCare Liberty (HMO SNP)
|
$8.70 |
$325* | to be determined | 1* |
Tier 1 |
$0.00 | $0.00 | P | $91.32 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$12.10 |
$325* | to be determined | 1* |
Tier 1 |
$0.00 | $0.00 | P | $91.32 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-103A (HMO SNP)
|
$12.20 |
$325* | to be determined | 1* |
Tier 1 |
$0.00 | $0.00 | P | $127.00 |
Browse Plan Formulary |
Coventry Summit Maximum (HMO SNP)
|
$18.20 |
$0 | to be determined | 3 |
Tier 3 |
$76.00 | $228.00 | P | $92.35 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$18.70 |
$325* | to be determined | 1* |
Tier 1 |
$0.00 | $0.00 | P | $91.18 |
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-I H1036-185 (HMO SNP)
|
$20.10 |
$325* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | P | $127.00 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-162 (HMO SNP)
|
$20.60 |
$325* | to be determined | 1* |
Tier 1 |
$0.00 | $0.00 | P | $127.00 |
Browse Plan Formulary |
Freedom Medi-Medi Full (HMO SNP)
|
$23.10 |
$325 | to be determined | 1 |
Tier 1 |
n/a | n/a | P | $86.49 |
Browse Plan Formulary |
CareNeeds PLUS (HMO SNP)
|
$23.20 |
$325* | to be determined | 1* |
Tier 1 |
$0.00 | $0.00 | P | $127.00 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax Plus (HMO SNP)
|
$23.40 |
$325* | to be determined | 1* |
Tier 1 |
$0.00 | n/a | P | $96.30 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$23.80 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | P | $89.85 |
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 |
Sunshine State Health Plan (HMO SNP)
|
$24.00 |
$325 | to be determined | 4 |
Tier 4 |
$95.00 | $95.00 | None | $95.74 |
Browse Plan Formulary |
Amerivantage Specialty + Rx (HMO SNP)
|
$24.70 |
$325 | Some Generics | 2 |
Non-Preferred Generic |
25% | 25% | P | $94.74 |
Browse Plan Formulary |
Coventry Vista Maximum (HMO SNP)
|
$24.70 |
$0 | to be determined | 3 |
Tier 3 |
$76.00 | $228.00 | P | $92.35 |
Browse Plan Formulary |
Freedom Medi-Medi Partial (HMO SNP)
|
$24.70 |
$325 | to be determined | 1 |
Tier 1 |
15% | 15% | P | $86.49 |
Browse Plan Formulary |
MediMax (HMO)
|
$24.70 |
$325* | No additional gap coverage, only the Donut Hole Discount | 2* |
Non-Preferred Generic |
25% | n/a | None | $87.48 |
Browse Plan Formulary |
CareNeeds (HMO SNP)
|
$24.80 |
$325* | to be determined | 1* |
Tier 1 |
$0.00 | $0.00 | P | $127.00 |
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 |
Optimum Emerald Full (HMO SNP)
|
$24.80 |
$325 | to be determined | 1 |
Tier 1 |
n/a | n/a | P | $86.49 |
Browse Plan Formulary |
Optimum Emerald Partial (HMO SNP)
|
$24.80 |
$325 | to be determined | 1 |
Tier 1 |
15% | 15% | P | $86.49 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP (Regional PPO SNP)
|
$24.80 |
$325 | to be determined | 3 |
Tier 3 |
15% | 15% | P | $89.85 |
Browse Plan Formulary |
Coventry Vista Maximum Choice (HMO SNP)
|
$25.50 |
$0 | to be determined | 3 |
Tier 3 |
$76.00 | $228.00 | P | $92.35 |
Browse Plan Formulary |
HumanaChoice R5826-005 (Regional PPO)
|
$28.10 |
$0 | Few Generics, Few Brands | 3 |
Preferred Brand |
$40.00 | $110.00 | P | $127.00 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$33.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$33.00 | $66.00 | P | $95.30 |
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 H5415-056 (PPO)
|
$42.00 |
$0 | Few Generics, Few Brands | 2 |
Preferred Brand |
$43.00 | $119.00 | P | $127.00 |
Browse Plan Formulary |
Day Break (HMO)
|
$68.00 |
$0 | All Generics | 3 |
Non-Preferred Brand |
$60.00 | $180.00 | P | $83.17 |
Browse Plan Formulary |
Humana Gold Choice H8145-061 (PFFS)
|
$102.00 |
$0 | Few Generics, Few Brands | 3 |
Preferred Brand |
$45.00 | $125.00 | P | $127.00 |
Browse Plan Formulary |
BlueMedicare PPO (PPO)
|
$152.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$17.00 | $24.00 | P | $82.63 |
Browse Plan Formulary |
HumanaChoice H5415-068 (PPO)
|
$152.00 |
$0 | Few Generics, Few Brands | 2 |
Preferred Brand |
$40.00 | $110.00 | P | $127.00 |
Browse Plan Formulary |