COLLAGENASE SANTYL OINTMENT 250UNT 30GM TUBE (30 GM TUBE) (NDC: 00064501030)
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 | $193.09 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 |
Few Generics |
2 |
Preferred Brand |
25% | 25% | None | $192.03 |
Browse Plan Formulary |
Blue Medicare Advantage Classic (HMO)
|
$0.00 |
$0 |
Few Generics |
3 |
Preferred Brand |
$45.00 | $135.00 | None | $190.60 |
Browse Plan Formulary |
CareMore Breathe (HMO SNP)
|
$0.00 |
$0 |
Many Generics, Few Brands |
4 |
Non-Preferred Brand |
$85.00 | $212.50 | Q:30 /1Days | $197.06 |
Browse Plan Formulary |
CareMore Diabetes (HMO SNP)
|
$0.00 |
$0 |
Many Generics, Few Brands |
4 |
Non-Preferred Brand |
$85.00 | $212.50 | Q:30 /1Days | $197.06 |
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 |
CareMore Heart (HMO SNP)
|
$0.00 |
$0 |
Many Generics, Few Brands |
4 |
Non-Preferred Brand |
$85.00 | $212.50 | Q:30 /1Days | $197.06 |
Browse Plan Formulary |
CareMore StartSmart Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:30 /1Days | $197.06 |
Browse Plan Formulary |
CareMore Value Plus (HMO)
|
$0.00 |
$0 |
Many Generics |
4 |
Non-Preferred Brand |
$85.00 | $212.50 | Q:30 /1Days | $197.06 |
Browse Plan Formulary |
Cigna Medicare Select Plus Rx-Diabetes Heart (HMO SNP)
|
$0.00 |
$0 |
Many Generics |
3 |
Preferred Brand |
$40.00 | $80.00 | None | $183.66 |
Browse Plan Formulary |
Cigna Medicare Select Plus Rx-Standard (HMO)
|
$0.00 |
$0 |
Many Generics |
3 |
Preferred Brand |
$40.00 | $80.00 | None | $183.66 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$44.00 | $122.00 | None | $190.08 |
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 |
Health Net Jade Cardiovascular (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$44.00 | $122.00 | None | $190.08 |
Browse Plan Formulary |
Health Net Ruby 4 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $190.06 |
Browse Plan Formulary |
Health Net Ruby Select (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$44.00 | $122.00 | None | $190.06 |
Browse Plan Formulary |
Heart First (HMO SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $194.66 |
Browse Plan Formulary |
Humana Gold Plus H2649-032 (HMO)
|
$0.00 |
$0 |
Few Generics, Few Brands |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $188.94 |
Browse Plan Formulary |
Humana Gold Plus SNP-CLD H2649-037 (HMO SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $188.94 |
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 |
Humana Gold Plus SNP-CVD/CHF/DM H2649-036 (HMO SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $188.94 |
Browse Plan Formulary |
Phoenix Advantage (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | None | $194.37 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $194.66 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $194.66 |
Browse Plan Formulary |
Blue Medicare Advantage Plus (HMO)
|
$17.00 |
$0 |
Few Generics |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $190.60 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$19.10 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $192.82 |
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 |
ONECare by Care1st Health Plan Arizona, Inc. (HMO SNP)
|
$23.70 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | n/a | None | $194.36 |
Browse Plan Formulary |
Advantage by Bridgeway Health Solutions (HMO SNP)
|
$27.40 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $193.25 |
Browse Plan Formulary |
Health Choice Generations (HMO SNP)
|
$27.40 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $186.24 |
Browse Plan Formulary |
Health Net Amber (HMO SNP)
|
$27.40 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$41.00 | $113.00 | None | $190.06 |
Browse Plan Formulary |
Maricopa Care Advantage (HMO SNP)
|
$27.50 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $191.64 |
Browse Plan Formulary |
Mercy Care Advantage (HMO SNP)
|
$27.50 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $190.87 |
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 |
Mercy Care Advantage (HMO SNP)
|
$27.50 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $190.87 |
Browse Plan Formulary |
Mercy Care Advantage (HMO SNP)
|
$27.50 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $190.87 |
Browse Plan Formulary |
Phoenix Advantage Plus (HMO SNP)
|
$27.50 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $195.08 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$27.50 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $192.92 |
Browse Plan Formulary |
HumanaChoice R5826-014 P (Regional PPO)
|
$32.30 |
$175 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $188.92 |
Browse Plan Formulary |
Phoenix Advantage Select (HMO)
|
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | None | $194.37 |
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 |
Health Net Ruby 1 (HMO)
|
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $190.03 |
Browse Plan Formulary |
Health Net Ruby 1 (HMO)
|
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $190.25 |
Browse Plan Formulary |
Health Net Ruby 1 (HMO)
|
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $190.06 |
Browse Plan Formulary |
Blue Medicare Advantage Premier (HMO)
|
$55.00 |
$0 |
Few Generics |
3 |
Preferred Brand |
$30.00 | $90.00 | None | $190.60 |
Browse Plan Formulary |
Humana Gold Plus H2649-030 (HMO-POS)
|
$79.00 |
$0 |
Few Generics, Few Brands |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $188.94 |
Browse Plan Formulary |
HumanaChoice H0317-001 (PPO)
|
$122.00 |
$0 |
Few Generics, Few Brands |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $188.94 |
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 |
Humana Gold Choice H8145-103 (PFFS)
|
$180.00 |
$0 |
Few Generics, Few Brands |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $188.97 |
Browse Plan Formulary |