AVELOX IV 400MG/250ML (250 ML CTR) (NDC: 00085173701)
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 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $527.70 |
Browse Plan Formulary |
AARP MedicareComplete Choice (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $527.70 |
Browse Plan Formulary |
AARP MedicareComplete Choice Plan 2 (Regional PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $525.90 |
Browse Plan Formulary |
BlueMedicare HMO LifeTime (HMO)
|
$0.00 |
$0 |
Many Generics |
3 |
Preferred Brand |
$35.00 | $105.00 | None | $529.23 |
Browse Plan Formulary |
BlueMedicare HMO PrimeTime (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $529.23 |
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 |
BlueMedicare Regional PPO (Regional PPO)
|
$0.00 |
$30 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | None | $524.43 |
Browse Plan Formulary |
CareDirect (HMO SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
4 |
Non-Preferred Brand |
$60.00 | $170.00 | None | $527.64 |
Browse Plan Formulary |
CareFree (HMO)
|
$0.00 |
$0 |
Few Generics, Few Brands |
4 |
Non-Preferred Brand |
$60.00 | $170.00 | None | $527.64 |
Browse Plan Formulary |
CareOne (HMO)
|
$0.00 |
$0 |
Some Generics, Few Brands |
4 |
Non-Preferred Brand |
$80.00 | $230.00 | None | $527.64 |
Browse Plan Formulary |
CareOne PLUS (HMO)
|
$0.00 |
$0 |
Some Generics, Few Brands |
4 |
Non-Preferred Brand |
$60.00 | $170.00 | None | $527.64 |
Browse Plan Formulary |
Coventry Summit Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None | $537.79 |
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 |
Day Break (HMO)
|
$0.00 |
$0 |
All Generics |
3 |
Non-Preferred Brand |
$60.00 | $180.00 | P | $534.50 |
Browse Plan Formulary |
Freedom Medicare Plan Rx (HMO)
|
$0.00 |
$0 |
Many Generics |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | P | $529.36 |
Browse Plan Formulary |
Freedom Savings Plan Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$90.00 | $180.00 | P | $529.96 |
Browse Plan Formulary |
Freedom VIP Care (HMO SNP)
|
$0.00 |
$0 |
Many Generics |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | P | $529.06 |
Browse Plan Formulary |
Freedom VIP Care COPD (HMO SNP)
|
$0.00 |
$0 |
Many Generics |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | P | $529.06 |
Browse Plan Formulary |
Freedom VIP Savings (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | P | $529.06 |
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 COPD (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | P | $529.06 |
Browse Plan Formulary |
Humana Gold Plus H1036-025 (HMO)
|
$0.00 |
$0 |
Some Generics, Few Brands |
4 |
Non-Preferred Brand |
$60.00 | $170.00 | None | $527.64 |
Browse Plan Formulary |
Humana Gold Plus H1036-141 (HMO)
|
$0.00 |
$0 |
Few Generics, Few Brands |
4 |
Non-Preferred Brand |
$60.00 | $170.00 | None | $527.64 |
Browse Plan Formulary |
Humana Gold Plus SNP-DB H1036-160 (HMO SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
4 |
Non-Preferred Brand |
$60.00 | $170.00 | None | $527.64 |
Browse Plan Formulary |
HumanaChoice R5826-074 (Regional PPO)
|
$0.00 |
$150 |
Few Generics, Few Brands |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $510.23 |
Browse Plan Formulary |
Optimum Diamond Rewards (HMO-POS SNP)
|
$0.00 |
$0 |
Many Generics |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | P | $525.76 |
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 Diamond Rewards COPD (HMO-POS SNP)
|
$0.00 |
$0 |
Many Generics |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | P | $525.76 |
Browse Plan Formulary |
Optimum Gold Rewards Plan (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | P | $526.66 |
Browse Plan Formulary |
Optimum Platinum Plan (HMO-POS)
|
$0.00 |
$0 |
Many Generics |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | P | $526.66 |
Browse Plan Formulary |
Preferred Secure Option (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $528.00 |
Browse Plan Formulary |
Simply Extra (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | n/a | None | $508.28 |
Browse Plan Formulary |
Simply Level (HMO SNP)
|
$0.00 |
$0 |
Many Generics, Few Brands |
4 |
Non-Preferred Brand |
$55.00 | n/a | None | $508.28 |
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 |
Simply More (HMO)
|
$0.00 |
$0 |
Many Generics |
4 |
Non-Preferred Brand |
$55.00 | n/a | None | $508.28 |
Browse Plan Formulary |
Sunrise (HMO)
|
$0.00 |
$0 |
All Generics |
3 |
Non-Preferred Brand |
$40.00 | $120.00 | P | $534.50 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-102 (HMO SNP)
|
$8.60 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $527.64 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-161 (HMO SNP)
|
$10.90 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $527.64 |
Browse Plan Formulary |
CareNeeds PLUS (HMO SNP)
|
$11.40 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $527.64 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete LP (HMO SNP)
|
$17.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $527.70 |
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)
|
$17.40 |
$0 |
All Generics |
3 |
Non-Preferred Brand |
25% | 25% | P | $534.50 |
Browse Plan Formulary |
Coventry Summit Maximum (HMO SNP)
|
$17.70 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$76.00 | $228.00 | None | $537.13 |
Browse Plan Formulary |
CareNeeds (HMO SNP)
|
$18.70 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $527.64 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$19.80 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $527.40 |
Browse Plan Formulary |
Advantage by Sunshine Health (HMO SNP)
|
$21.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Injectable Drugs |
$95.00 | $95.00 | None | $526.11 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP (Regional PPO SNP)
|
$21.80 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $525.90 |
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 |
Freedom Medi-Medi Full (HMO SNP)
|
$22.10 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
n/a | n/a | P | $529.06 |
Browse Plan Formulary |
Freedom Medi-Medi Partial (HMO SNP)
|
$22.10 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P | $529.06 |
Browse Plan Formulary |
Optimum Emerald Full (HMO SNP)
|
$22.10 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
n/a | n/a | P | $529.06 |
Browse Plan Formulary |
Optimum Emerald Partial (HMO SNP)
|
$22.10 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P | $529.06 |
Browse Plan Formulary |
Simply Care (HMO SNP)
|
$22.10 |
$0 |
Many Generics |
4 |
Non-Preferred Brand |
$90.00 | n/a | None | $508.28 |
Browse Plan Formulary |
Simply Comfort (HMO SNP)
|
$22.10 |
$0 |
Many Generics |
4 |
Non-Preferred Brand |
$90.00 | n/a | None | $508.28 |
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 |
Simply Complete (HMO SNP)
|
$22.10 |
$310 |
Many Generics |
4 |
Non-Preferred Brand |
$90.00 | n/a | None | $508.28 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$35.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $520.73 |
Browse Plan Formulary |
Clear Skies (HMO SNP)
|
$35.20 |
$0 |
All Generics |
3 |
Non-Preferred Brand |
$40.00 | $120.00 | P | $534.50 |
Browse Plan Formulary |
HumanaChoice R5826-005 (Regional PPO)
|
$36.60 |
$0 |
Few Generics, Few Brands |
4 |
Non-Preferred Brand |
$85.00 | $245.00 | None | $510.23 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$37.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $520.73 |
Browse Plan Formulary |
Humana Gold Choice H8145-061 (PFFS)
|
$103.00 |
$0 |
Few Generics, Few Brands |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $510.23 |
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 |
BlueMedicare PPO (PPO)
|
$127.00 |
$0 |
Many Generics |
3 |
Preferred Brand |
$30.00 | $90.00 | None | $518.73 |
Browse Plan Formulary |