AMIFOSTINE 50mg/mL 3 VIAL, SINGLE-USE per CARTON / 10 mL in 1 VIAL, SINGLE-USE (3 VIAL, SINGLE-USE in 1 C ) (NDC: 47335058142)
2014 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 Plan 1 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | None | $1,380.54 |
Browse Plan Formulary |
Commonwealth Care Alliance (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
All Generics, All Brands |
1 |
Tier 1 |
0% | 0% | None | $1,345.88 |
Browse Plan Formulary |
Fallon Senior Plan Super Saver Rx (HMO)
|
$0.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | P | $1,422.07 |
Browse Plan Formulary |
Fallon Senior Plan Super Saver Rx (HMO)
|
$0.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | P | $1,422.07 |
Browse Plan Formulary |
Fallon Senior Plan Super Saver Rx (HMO)
|
$0.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | P | $1,422.07 |
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 |
Fallon Senior Plan Super Saver Rx (HMO)
|
$0.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | P | $1,422.07 |
Browse Plan Formulary |
Fallon Senior Plan Super Saver Rx (HMO)
|
$0.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | P | $1,422.07 |
Browse Plan Formulary |
Fallon Total Care (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
All Generics, All Brands |
1 |
Tier 1 |
0% | 0% | P | $1,424.15 |
Browse Plan Formulary |
Medicare PPO Blue SaverRx (PPO)
|
$0.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | None | $1,474.60 |
Browse Plan Formulary |
Network Health Unify (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
All Generics, All Brands |
1 |
Tier 1 |
0% | 0% | None | $1,501.79 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Saver Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $24.00 | None | $1,501.79 |
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 Senior Care Options (HMO SNP)
|
$13.50 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
n/a | n/a | None | $1,380.54 |
Browse Plan Formulary |
AARP MedicareComplete Choice (Regional PPO)
|
$19.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | None | $1,380.54 |
Browse Plan Formulary |
Tufts Health Plan Senior Care Options (HMO SNP)
|
$22.50 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
n/a | n/a | None | $1,501.79 |
Browse Plan Formulary |
Medicare HMO Blue ValueRx (HMO)
|
$26.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | None | $1,474.60 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$26.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | None | $1,380.54 |
Browse Plan Formulary |
NaviCare (HMO SNP)
|
$28.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
25% | 25% | P | $1,422.07 |
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 |
Senior Whole Health (HMO SNP)
|
$28.00 |
$310 |
Call plan for details |
3 |
Specialty Tier |
25% | 25% | None | $1,474.58 |
Browse Plan Formulary |
Senior Whole Health NHC (HMO SNP)
|
$28.00 |
$310 |
Call plan for details |
3 |
Specialty Tier |
25% | 25% | None | $1,474.58 |
Browse Plan Formulary |
Senior Care Options Program (HMO SNP)
|
$30.90 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
n/a | n/a | None | $1,345.88 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$35.90 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $24.00 | None | $1,501.79 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$35.90 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $24.00 | None | $1,501.79 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$35.90 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $24.00 | None | $1,501.79 |
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 |
Fallon Senior Plan Saver Enhanced RX (HMO)
|
$37.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P | $1,422.07 |
Browse Plan Formulary |
Fallon Senior Plan Saver Enhanced RX (HMO)
|
$37.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P | $1,422.07 |
Browse Plan Formulary |
Fallon Senior Plan Saver Enhanced RX (HMO)
|
$37.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P | $1,422.07 |
Browse Plan Formulary |
Fallon Senior Plan Saver Enhanced RX (HMO)
|
$37.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P | $1,422.07 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$45.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | None | $1,380.54 |
Browse Plan Formulary |
Medicare PPO Blue ValueRx (PPO)
|
$51.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | None | $1,474.60 |
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 |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$117.90 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $24.00 | None | $1,501.79 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$117.90 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $24.00 | None | $1,501.79 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$117.90 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $24.00 | None | $1,501.79 |
Browse Plan Formulary |
Medicare PPO Blue PlusRx (PPO)
|
$124.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | 30% | None | $1,474.60 |
Browse Plan Formulary |
Fallon Senior Plan Plus Enhanced RX (HMO)
|
$143.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P | $1,422.07 |
Browse Plan Formulary |
Fallon Senior Plan Plus Enhanced RX (HMO)
|
$143.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P | $1,422.07 |
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 |
Fallon Senior Plan Plus Enhanced RX (HMO)
|
$143.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P | $1,422.07 |
Browse Plan Formulary |
Fallon Senior Plan Plus Enhanced RX (HMO)
|
$143.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P | $1,422.07 |
Browse Plan Formulary |
Fallon Senior Plan Plus Enhanced RX (HMO)
|
$143.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P | $1,422.07 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$151.90 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $24.00 | None | $1,501.79 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$151.90 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $24.00 | None | $1,501.79 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$151.90 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $24.00 | None | $1,501.79 |
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 |
Medicare HMO Blue PlusRx (HMO)
|
$167.00 |
$120 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | 30% | None | $1,474.60 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$185.70 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$5.00 | $12.00 | None | $1,501.79 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$185.70 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$5.00 | $12.00 | None | $1,501.79 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$185.70 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$5.00 | $12.00 | None | $1,501.79 |
Browse Plan Formulary |