Atelvia 35mg/1 36 DOSE PACK CASE / 4 TABLET, DELAYED RELEASE in 1 DOSE PACK (36 DOSE PACK in 1 CASE / ) (NDC: 00430097903)
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)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$92.00 | $266.00 | None | $149.33 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$92.00 | $266.00 | None | $149.33 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $149.33 |
Browse Plan Formulary |
Access Medicare Gold (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$70.00 | $105.00 | Q:4 /28Days | $146.32 |
Browse Plan Formulary |
Elderplan Classic: Zero Premium (HMO)
|
$0.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$30.00 | $75.00 | S Q:4 /28Days | $150.08 |
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 |
Fidelis Medicare $0 Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$75.00 | $150.00 | None | $149.20 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$80.00 | $200.00 | None | $148.64 |
Browse Plan Formulary |
Healthfirst Jade Benefits Plan (HMO)
|
$0.00 |
$0 |
Many Generics, Few Brands |
3 |
Non-Preferred Brand |
$80.00 | $200.00 | None | $148.64 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (Regional PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $149.34 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Enhanced (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None | $148.64 |
Browse Plan Formulary |
Healthfirst Increased Benefits Plan (HMO)
|
$35.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | None | $148.64 |
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 Nursing Home Plan (HMO SNP)
|
$35.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $149.33 |
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 | $150.13 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Preferred (HMO SNP)
|
$40.10 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $148.64 |
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% | S Q:4 /28Days | $150.08 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$41.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
n/a | n/a | None | $149.33 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete LP (HMO SNP)
|
$42.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $149.33 |
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 |
Healthfirst AssuredCare (HMO SNP)
|
$43.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | None | $148.64 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO SNP)
|
$43.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
n/a | n/a | None | $148.64 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO SNP)
|
$43.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $148.64 |
Browse Plan Formulary |
Healthfirst Maximum Plan (HMO SNP)
|
$43.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
n/a | n/a | None | $148.64 |
Browse Plan Formulary |
Access Medicare Pearl (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:4 /28Days | $146.32 |
Browse Plan Formulary |
Access Medicare Platinum (HMO)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:4 /28Days | $146.32 |
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 |
Access Medicare Silver (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:4 /28Days | $146.32 |
Browse Plan Formulary |
ArchCare - Inst and IE SNP - All Counties (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | None | $149.85 |
Browse Plan Formulary |
CenterLight Direct Complete Plan (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$42.00 | $126.00 | Q:12 /90Days | $153.67 |
Browse Plan Formulary |
CenterLight Direct Total Plan (HMO SNP)
|
$43.20 |
$185 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$45.00 | $135.00 | Q:12 /90Days | $153.67 |
Browse Plan Formulary |
Elderplan Extra Help (HMO)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | S Q:4 /28Days | $150.08 |
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% | S Q:4 /28Days | $150.08 |
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 |
Elderplan Medicaid Advantage (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | S Q:4 /28Days | $150.08 |
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% | S Q:4 /28Days | $150.08 |
Browse Plan Formulary |
Fidelis Dual Advantage (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None | $149.20 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO SNP)
|
$43.20 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $149.21 |
Browse Plan Formulary |
Fidelis Long Term Care Advantage (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $149.21 |
Browse Plan Formulary |
Fidelis Medicaid Advantage Plus (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$91.00 | $182.00 | None | $149.20 |
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 Medicare Advantage Flex (HMO-POS)
|
$43.20 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$70.00 | $140.00 | None | $149.21 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Maximum (HMO SNP)
|
$78.50 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
n/a | n/a | None | $148.64 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO SNP)
|
$95.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
n/a | n/a | None | $148.64 |
Browse Plan Formulary |