ACTEMRA 162 MG/0.9 ML SYRINGE (9 ML ) (NDC: 50242013801)
2015 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 |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $793.39 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $793.39 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $793.39 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $793.39 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $793.39 |
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 |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | P Q:4 /28Days | $767.13 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | P Q:4 /28Days | $794.44 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | P Q:4 /28Days | $789.33 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | P Q:4 /28Days | $794.44 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | P Q:4 /28Days | $789.33 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | P | $793.39 |
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 Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | P | $793.39 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | P | $793.39 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | P | $793.39 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | P | $793.39 |
Browse Plan Formulary |
Paramount Elite - Standard Medical and Drug (HMO)
|
$23.00 |
$100* | No additional gap coverage, only the Donut Hole Discount | 5* |
Specialty Tier |
33% | n/a | P | $772.73 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$52.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
31% | n/a | P Q:4 /28Days | $789.33 |
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 |
Paramount Elite - Enhanced Medical and Drug (HMO)
|
$68.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $772.73 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$71.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:4 /28Days | $767.13 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$71.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:4 /28Days | $794.44 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$71.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:4 /28Days | $789.33 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$71.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:4 /28Days | $789.33 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$71.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:4 /28Days | $794.44 |
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 Plus Blue PPO Vitality (PPO)
|
$75.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | P | $793.39 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$75.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | P | $793.39 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$75.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | P | $793.39 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$75.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | P | $793.39 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$75.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | P | $793.39 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $793.39 |
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 |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $793.39 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $793.39 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $793.39 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $793.39 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$136.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:4 /28Days | $789.33 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$145.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:4 /28Days | $794.44 |
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 |
PriorityMedicare Select (PPO)
|
$145.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:4 /28Days | $794.44 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$145.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:4 /28Days | $789.33 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$145.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:4 /28Days | $789.33 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$145.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:4 /28Days | $767.13 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$162.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
30% | n/a | P | $793.39 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$162.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
30% | n/a | P | $793.39 |
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 Plus Blue PPO Signature (PPO)
|
$162.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
30% | n/a | P | $793.39 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$162.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
30% | n/a | P | $793.39 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$162.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
30% | n/a | P | $793.39 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$238.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $793.39 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$238.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $793.39 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$238.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $793.39 |
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 Plus Blue PPO Assure (PPO)
|
$238.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $793.39 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$238.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $793.39 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$262.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $793.39 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$262.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $793.39 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$262.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $793.39 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$262.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $793.39 |
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 |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$262.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $793.39 |
Browse Plan Formulary |