2013 Medicare Prescription Drug Price Information | ||||||
MedicareBlue Rx Premier (PDP) (S5743-004-0) Benefit Details ![]() ![]() ![]() ![]() | ||||||
Click on a letter below to view the MedicareBlue Rx Premier (PDP) 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 | ||||||
NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M ![]() | ||||||
Plan’s average negotiated retail drug price in CMS PDP Region 25, includes: IA MN MT NE ND SD WY | $40.38* 30-Day Supply $118.21* 90-Day Supply | |||||
Formulary (Drug List) drug tier: | Tier #2: Non-Preferred Generic | |||||
Does this plan offer any Gap coverage? | All Generics | |||||
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** | |
This plan does not have an Initial Deductible: | ||||||
n/a | n/a | n/a | n/a | n/a | n/a | |
Initial Coverage Phase Cost-Sharing: | ||||||
$12.00 | $12.00 | n/a | $36.00 | $36.00 | $24.00 | |
Coverage Gap Phase Cost-Sharing Incl. Donut Hole Discount (Generics 21%): | ||||||
79% | 79% | n/a | 79% | 79% | 79% | |
Coverage Gap Phase Cost-Sharing Incl. Donut Hole Discount (Brand 52.5%): | ||||||
47.5% | 47.5% | n/a | 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 Initial Coverage Phase: | ||||||
$12.00 | $12.00 | n/a | $36.00 | $36.00 | $24.00 | |
Your Estimated Cost in Gap if Drug is Generic (21% discount): | ||||||
Your Estimated Cost in Gap if Drug is Brand-Name (52.5% discount): | ||||||
$19.18 | $19.18 | $19.18 | $56.15 | $56.15 | $56.15 | |
Your Estimated Cost in Catastrophic Coverage Phase (Generic): | ||||||
$2.65 | $2.65 | n/a | $5.91 | $5.91 | $5.91 | |
Your Estimated Cost in Catastrophic Coverage (Brand-Name or Non-Preferred Multi-Source Drugs): | ||||||
$6.60 | $6.60 | n/a | $6.60 | $6.60 | $6.60 | |
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 --- | ||||||
This plan does not have an Initial Deductible: | ||||||
n/a | n/a | n/a | n/a | n/a | n/a | |
--- If you purchase during the Initial Coverage Phase --- | ||||||
Initial Coverage Phase Cost-Sharing: | ||||||
$12.00 | $12.00 | n/a | $36.00 | $36.00 | $24.00 | |
Your Estimated Cost Initial Coverage Phase: | ||||||
$12.00 | $12.00 | n/a | $36.00 | $36.00 | $24.00 | |
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 $12.00. | ||||||
--- 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): | ||||||
$19.18 | $19.18 | $19.18 | $56.15 | $56.15 | $56.15 | |
--- 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): | ||||||
$2.65 | $2.65 | n/a | $5.91 | $5.91 | $5.91 | |
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 $40.38 = $2.02. Since $2.02 is less than $2.65, you would pay $2.65 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 | n/a | $6.60 | $6.60 | $6.60 | |
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 $40.38 = $2.02. Since $2.02 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. | ||||||
MedicareBlue Rx Premier (PDP) Average Negotiated Retail Drug Price History | ||||||
30-Day Supply | 90 Day Supply | |||||
October, 2013: | $40.38 | $118.21 | ||||
January, 2013: | $21.13 | -- | ||||
April, 2012: | $21.16 | -- | ||||
September, 2010: | $21.58 | -- | ||||
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 NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M prices that the MedicareBlue Rx Premier (PDP) has negotiated with each of the retail pharmacies in the plan’s service area (CMS PDP Region 25, includes: IA MN MT NE ND SD WY). In other words, when you use the MedicareBlue Rx Premier (PDP) to purchase NEOMYCIN/POLYMY/GRAM EYE DROPS 0.025MG/ML 1.75MG/M, 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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