2013 Medicare Advantage Prescription Drug Price Information | ||||||
Amerivantage Specialty + Rx (HMO SNP) (H5817-009-0) Benefit Details | ||||||
Click on a letter below to view the Amerivantage Specialty + Rx (HMO SNP) Formulary A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 0-9 | ||||||
STAVUDINE CAPSULES 40MG 60 BOT | ||||||
Plan’s average negotiated retail drug price in in TARRANT, TX: CMS MA Region 17, includes: TX | $104.27* 30-Day Supply $310.67* 90-Day Supply | |||||
Formulary (Drug List) drug tier: | Tier #2: Non-Preferred Generic This Tier has No Deductible. | |||||
Does this plan offer any Gap coverage? | Many Generics and Few Brands | |||||
Does this drug have Gap coverage? | No, this drug IS NOT covered in the gap, but all drugs receive the donut hole discount. | |||||
Drug Usage Management Restrictions: | None | |||||
Formulary (Drug List) Tier Cost-Sharing Details | ||||||
30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing |
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Preferred Pharmacy | Standard Pharmacy | Mail- Order** | Preferred Pharmacy | Standard Pharmacy | Mail- Order** | |
Initial $325 Deductible Cost Sharing: | ||||||
$0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |
Initial Coverage Phase Cost-Sharing: | ||||||
$0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |
Coverage Gap Phase Cost-Sharing Incl. Donut Hole Discount (Generics 21%): | ||||||
79% | 79% | 79% | 79% | 79% | 79% | |
Coverage Gap Phase Cost-Sharing Incl. Donut Hole Discount (Brand 52.5%): | ||||||
47.5% | 47.5% | 47.5% | 47.5% | 47.5% | 47.5% | |
Catastrophic Coverage Phase Cost-Sharing for Generic & Preferred Multi-Source Drugs: | ||||||
The greater of 5% or $2.65 | The greater of 5% or $2.65 | |||||
Catastrophic Coverage Phase Cost-Sharing for Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | ||||||
The greater of 5% or $6.60 | The greater of 5% or $6.60 | |||||
Your Estimated Cost for Purchases During Each Coverage Phase | ||||||
30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing |
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Preferred Pharmacy | Standard Pharmacy | Mail- Order** | Preferred Pharmacy | Standard Pharmacy | Mail- Order** | |
Your Estimated Cost in Deductible Phase: | ||||||
$0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |
Your Estimated Cost Initial Coverage Phase: | ||||||
$0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |
Your Estimated Cost in Gap if Drug is Generic (21% discount): | ||||||
Your Estimated Cost in Gap if Drug is Brand-Name (52.5% discount): | ||||||
$49.53 | $49.53 | $49.53 | $147.57 | $147.57 | $147.57 | |
Your Estimated Cost in Catastrophic Coverage Phase (Generic): | ||||||
$5.21 | $5.21 | $5.21 | $15.53 | $15.53 | $15.53 | |
Your Estimated Cost in Catastrophic Coverage (Brand-Name or Non-Preferred Multi-Source Drugs): | ||||||
$6.60 | $6.60 | $6.60 | $15.53 | $15.53 | $15.53 | |
Tier Cost-Sharing Details and Your Costs with Explanations | ||||||
30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing |
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Preferred Pharmacy | Standard Pharmacy | Mail- Order** | Preferred Pharmacy | Standard Pharmacy | Mail- Order** | |
--- If you purchase during the Initial Deductible Phase --- | ||||||
Initial $325 Deductible Cost Sharing: | ||||||
$0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |
Your Estimated Cost in Deductible Phase: | ||||||
$0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |
Explanation for 30-Day Preferred Pharmacy purchase: | ||||||
This plan has coverage for all Tier 2 drugs during the initial deductible phase. Although this plan has an initial deductible, Tier 2 drugs have no deductible. So you play the same during the deductible phase ($0.00), as you would in the initial coverage phase. This purchase would not count toward meeting your deductible. | ||||||
--- If you purchase during the Initial Coverage Phase --- | ||||||
Initial Coverage Phase Cost-Sharing: | ||||||
$0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |
Your Estimated Cost Initial Coverage Phase: | ||||||
$0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | |
Explanation for 30-Day Preferred Pharmacy purchase: | ||||||
The cost-sharing for purchases made during the initial coverage phase (ICP) would be a flat fee of $0.00. | ||||||
--- If you purchase during the Coverage Gap Phase (Donut Hole) --- | ||||||
Your Estimated Cost in Gap if Drug is Generic (21% discount): | ||||||
Your Estimated Cost in Gap if Drug is Brand-Name (52.5% discount): | ||||||
$49.53 | $49.53 | $49.53 | $147.57 | $147.57 | $147.57 | |
--- If you purchase during the Catastrophic Coverage Phase --- | ||||||
Catastrophic Coverage Phase Cost-Sharing for Generic & Preferred Multi-Source Drugs: | ||||||
The greater of 5% or $2.65 | The greater of 5% or $2.65 | |||||
Your Estimated Cost in Catastrophic Coverage Phase (Generic): | ||||||
$5.21 | $5.21 | $5.21 | $15.53 | $15.53 | $15.53 | |
Explanation for 30-Day Preferred Pharmacy purchase: | ||||||
In the catastrophic coverage phase, you will pay the greater of 5% of the retail drug price or the minimum cost-share of $2.65. Calculating 5% of $104.27 = $5.21. Since $5.21 is more than $2.65, you would pay $5.21 for this drug at a preferred pharmacy, if it is a generic or preferred multi-source drug. | ||||||
Catastrophic Coverage Phase Cost-Sharing for Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | ||||||
The greater of 5% or $6.60 | The greater of 5% or $6.60 | |||||
Your Estimated Cost in Catastrophic Coverage (Brand-Name or Non-Preferred Multi-Source Drugs): | ||||||
$6.60 | $6.60 | $6.60 | $15.53 | $15.53 | $15.53 | |
Explanation for 30-Day Preferred Pharmacy purchase: | ||||||
In the catastrophic coverage phase, you will pay the greater of 5% of the retail drug price or the minimum cost-share of $6.60. Calculating 5% of $104.27 = $5.21. Since $5.21 is less than $6.60, you would pay $6.60 for this drug at any pharmacy, if it is not a generic or preferred multi-source drug. | ||||||
Amerivantage Specialty + Rx (HMO SNP) Average Negotiated Retail Drug Price History | ||||||
30-Day Supply | 90 Day Supply | |||||
October, 2013: | $104.27 | $310.67 | ||||
January, 2013: | $109.85 | -- | ||||
April, 2012: | $110.96 | -- | ||||
September, 2010: | $57.98 | -- | ||||
Notes:
*The Medicare drug plan’s average negotiated retail drug price is based on several variables: the medication, the quantity of your prescription, the specific Medicare Part D plan, and the pharmacies in the plan’s service area. In this case, the average of the STAVUDINE CAPSULES 40MG 60 BOT prices that the Amerivantage Specialty + Rx (HMO SNP) has negotiated with each of the retail pharmacies in the plan’s service area (in TARRANT, TX: CMS MA Region 17, includes: TX). In other words, when you use the Amerivantage Specialty + Rx (HMO SNP) to purchase STAVUDINE CAPSULES 40MG 60 BOT, you may pay slightly more or slightly less than the figures shown in the table above depending on the pharmacy where you fill your prescription and the quantity of your prescription. **The mail-order cost-sharing is the plan’s "preferred" mail-order cost-sharing. |
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