PHENYTOIN SODIUM 50mg/mL 25 VIAL, SINGLE-DOSE in 1 CARTON / 2 mL in 1 VIAL, SINGLE-DOSE (25 VIAL, SINGLE-DOSE in 1 ) (NDC: 39822405003)
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 |
2 |
Non-Preferred Generic |
$6.00 | $12.00 | None | $25.81 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
|
$0.00 |
$0 |
Some Generics |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None | $26.79 |
Browse Plan Formulary |
AARP MedicareComplete Plus (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None | $26.79 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$7.00 | $14.00 | None | $11.66 |
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 | None | $24.90 |
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 | $28.75 |
Browse Plan Formulary |
CareFree PLUS (HMO)
|
$0.00 |
$0 |
Few Generics, Few Brands |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $37.65 |
Browse Plan Formulary |
CareHeart (HMO SNP)
|
$0.00 |
$0 |
Many Generics, Few Brands |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $37.65 |
Browse Plan Formulary |
CareOne PLUS (HMO)
|
$0.00 |
$0 |
Many Generics, Few Brands |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $37.65 |
Browse Plan Formulary |
Clear Skies (HMO SNP)
|
$0.00 |
$0 |
All Generics |
3 |
Non-Preferred Brand |
$20.00 | $60.00 | P | $22.36 |
Browse Plan Formulary |
Coventry Summit Ideal (HMO-POS)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $27.32 |
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 |
Coventry Summit Plus (HMO)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $27.32 |
Browse Plan Formulary |
Coventry Vista Ideal (HMO)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $27.32 |
Browse Plan Formulary |
Day Break (HMO)
|
$0.00 |
$0 |
All Generics |
3 |
Non-Preferred Brand |
$20.00 | $60.00 | P | $22.36 |
Browse Plan Formulary |
Freedom Medicare Plan Rx (HMO)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $22.27 |
Browse Plan Formulary |
Freedom VIP Care (HMO SNP)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $21.22 |
Browse Plan Formulary |
Freedom VIP Care COPD (HMO SNP)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $21.22 |
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 VIP Savings (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $21.22 |
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 | None | $21.22 |
Browse Plan Formulary |
Healthy Advantage Plan (HMO)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | n/a | None | $27.12 |
Browse Plan Formulary |
Humana Gold Plus H1036-054C (HMO)
|
$0.00 |
$0 |
Many Generics, Few Brands |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $37.65 |
Browse Plan Formulary |
Humana Gold Plus H1036-164 (HMO)
|
$0.00 |
$0 |
Few Generics, Few Brands |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $37.65 |
Browse Plan Formulary |
Humana Gold Plus SNP-CVD/CHF H1036-189 (HMO SNP)
|
$0.00 |
$0 |
Many Generics, Few Brands |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $37.65 |
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-DB H1036-188 (HMO SNP)
|
$0.00 |
$0 |
Many Generics, Few Brands |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $37.65 |
Browse Plan Formulary |
Humana Reader''s Digest Healthy Living Plan (Regional PPO)
|
$0.00 |
$0 |
Few Generics, Few Brands |
2 |
Non-Preferred Generic |
$15.00 | $0.00 | None | $38.06 |
Browse Plan Formulary |
Leon Medical Centers Health Plans - Leon Cares (HMO)
|
$0.00 |
$0 |
All Generics |
1 |
Generic |
$0.00 | n/a | None | $26.29 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax (HMO)
|
$0.00 |
$0 |
Many Generics |
1 |
Generic |
$0.00 | n/a | None | $28.66 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax Chronic Care (HMO SNP)
|
$0.00 |
$0 |
Many Generics |
1 |
Generic |
$0.00 | n/a | None | $28.66 |
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 | None | $29.25 |
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 Gold Rewards Plan (HMO-POS)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $26.85 |
Browse Plan Formulary |
Optimum Platinum Plan (HMO-POS)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $26.85 |
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 | $27.79 |
Browse Plan Formulary |
Preferred Medical Plan Choice (HMO)
|
$0.00 |
$0 |
Many Generics, Some Brands |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $26.56 |
Browse Plan Formulary |
Preferred Medical Plan Value (HMO)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $26.56 |
Browse Plan Formulary |
PUP REWARDS (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $24.46 |
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 |
SunPlus Advantage Plan (HMO)
|
$0.00 |
$0 |
All Generics, All Brands |
1 |
Preferred Generic |
$0.00 | n/a | None | $27.12 |
Browse Plan Formulary |
SunPlus Diabetes Special Needs Plan (HMO SNP)
|
$0.00 |
$0 |
All Generics, All Brands |
1 |
Preferred Generic |
$0.00 | n/a | None | $27.12 |
Browse Plan Formulary |
Sunrise (HMO)
|
$0.00 |
$0 |
All Generics |
3 |
Non-Preferred Brand |
$20.00 | $60.00 | P | $22.36 |
Browse Plan Formulary |
WellCare Choice (HMO)
|
$0.00 |
$0 |
All Generics, All Brands |
1 |
Generic |
$0.00 | $0.00 | None | $27.73 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$0 |
All Generics |
1 |
Generic |
$0.00 | $0.00 | None | $27.73 |
Browse Plan Formulary |
PUP EXTRA (HMO SNP)
|
$4.90 |
$0 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | None | $26.38 |
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 |
Sunny Days (HMO SNP)
|
$4.90 |
$325 |
to be determined |
3 |
Tier 3 |
15% | 15% | P | $22.36 |
Browse Plan Formulary |
WellCare Select (HMO-POS SNP)
|
$8.50 |
$325* |
to be determined |
1* |
Tier 1 |
$0.00 | $0.00 | None | $29.11 |
Browse Plan Formulary |
WellCare Liberty (HMO SNP)
|
$11.80 |
$0 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | None | $27.73 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$12.20 |
$0 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | None | $27.73 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-077A (HMO SNP)
|
$17.90 |
$325* |
to be determined |
1* |
Tier 1 |
$0.00 | $0.00 | None | $37.65 |
Browse Plan Formulary |
Coventry Summit Maximum (HMO SNP)
|
$18.20 |
$0 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | None | $28.74 |
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 |
Molina Medicare Options Plus (HMO SNP)
|
$18.70 |
$325* |
to be determined |
1* |
Tier 1 |
$0.00 | $0.00 | None | $24.26 |
Browse Plan Formulary |
CareNeeds (HMO SNP)
|
$20.30 |
$325* |
to be determined |
1* |
Tier 1 |
$0.00 | $0.00 | None | $37.65 |
Browse Plan Formulary |
Humana Gold Plus SNP-I H1036-187 (HMO SNP)
|
$21.30 |
$325* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $37.65 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-163 (HMO SNP)
|
$21.90 |
$325* |
to be determined |
1* |
Tier 1 |
$0.00 | $0.00 | None | $37.65 |
Browse Plan Formulary |
Freedom Medi-Medi Full (HMO SNP)
|
$23.10 |
$325 |
to be determined |
1 |
Tier 1 |
n/a | n/a | None | $22.99 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax Plus (HMO SNP)
|
$23.40 |
$325* |
to be determined |
1* |
Tier 1 |
$0.00 | n/a | None | $29.25 |
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 | $26.10 |
Browse Plan Formulary |
Amerivantage Specialty + Rx (HMO SNP)
|
$24.70 |
$325 |
Some Generics |
2 |
Non-Preferred Generic |
25% | 25% | None | $24.90 |
Browse Plan Formulary |
Coventry Vista Maximum (HMO SNP)
|
$24.70 |
$0 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | None | $28.74 |
Browse Plan Formulary |
Freedom Medi-Medi Partial (HMO SNP)
|
$24.70 |
$325 |
to be determined |
1 |
Tier 1 |
15% | 15% | None | $22.99 |
Browse Plan Formulary |
MediMax (HMO)
|
$24.70 |
$325* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
25% | n/a | None | $27.43 |
Browse Plan Formulary |
CareNeeds PLUS (HMO SNP)
|
$24.80 |
$325* |
to be determined |
1* |
Tier 1 |
$0.00 | $0.00 | None | $37.65 |
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 | None | $22.99 |
Browse Plan Formulary |
Optimum Emerald Partial (HMO SNP)
|
$24.80 |
$325 |
to be determined |
1 |
Tier 1 |
15% | 15% | None | $22.99 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP (Regional PPO SNP)
|
$24.80 |
$325 |
to be determined |
2 |
Tier 2 |
15% | 15% | None | $25.81 |
Browse Plan Formulary |
Coventry Vista Maximum Choice (HMO SNP)
|
$25.50 |
$0 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | None | $28.74 |
Browse Plan Formulary |
HumanaChoice R5826-005 (Regional PPO)
|
$28.10 |
$0 |
Few Generics, Few Brands |
2 |
Non-Preferred Generic |
$8.00 | $0.00 | None | $38.06 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$33.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$7.00 | $14.00 | None | $23.75 |
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 |
1 |
Preferred Generic |
$6.00 | $0.00 | None | $37.65 |
Browse Plan Formulary |
Humana Gold Choice H8145-061 (PFFS)
|
$102.00 |
$0 |
Few Generics, Few Brands |
2 |
Non-Preferred Generic |
$15.00 | $0.00 | None | $38.06 |
Browse Plan Formulary |