AMINOSYN II 8.5% ELECTROLYT (13 X 500 ML BAG) (NDC: 00409417103)
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 |
Fidelis Secure Respect (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$45.00 | $90.00 | P | $133.51 |
Browse Plan Formulary |
Meridian Prime (HMO)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | P | $132.32 |
Browse Plan Formulary |
Erickson Advantage Guardian (HMO-POS SNP)
|
$2.90 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$70.00 | $200.00 | P | $120.20 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | P | $133.51 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | P | $133.51 |
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 |
3 |
Tier 3 |
25% | 25% | P | $133.51 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | P | $133.51 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | P | $133.51 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | P | $135.02 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | P | $135.02 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | P | $135.02 |
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 |
4 |
Tier 4 |
25% | 25% | P | $135.02 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | P | $135.02 |
Browse Plan Formulary |
HumanaChoice R5826-006 (Regional PPO)
|
$28.20 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | P | $132.54 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$28.60 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | P | $130.63 |
Browse Plan Formulary |
Fidelis Secure Comfort (HMO SNP)
|
$30.40 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | P | $133.51 |
Browse Plan Formulary |
Meridian Advantage Plan of Michigan (HMO SNP)
|
$31.40 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P | $132.32 |
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 |
Fidelis Secure Freedom (HMO SNP)
|
$31.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$35.00 | $70.00 | P | $133.51 |
Browse Plan Formulary |
Fidelis Secure Liberty (HMO SNP)
|
$31.50 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | P | $133.51 |
Browse Plan Formulary |
Erickson Advantage Freedom (HMO-POS)
|
$48.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$85.00 | $245.00 | P | $120.20 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$55.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | P | $120.63 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$58.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | P | $133.51 |
Browse Plan Formulary |
Fidelis Secure Premier (HMO)
|
$64.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Preferred Brand |
$40.00 | $80.00 | P | $133.51 |
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 |
HAP Senior Plus - Henry Ford (HMO)
|
$76.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | P | $120.63 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | P | $133.51 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | P | $133.51 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | P | $133.51 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | P | $133.51 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | P | $133.51 |
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)
|
$100.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | P | $135.02 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$100.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | P | $135.02 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$100.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | P | $135.02 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$100.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | P | $135.02 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$100.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | P | $135.02 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$106.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | P | $120.63 |
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 |
Alliance Medicare PPO (PPO)
|
$126.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | P | $120.63 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$146.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $100.00 | P | $133.51 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$159.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P | $135.02 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$159.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P | $135.02 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$159.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P | $135.02 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$159.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P | $135.02 |
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)
|
$159.00 |
$95 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P | $135.02 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$178.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $100.00 | P | $133.51 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$178.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $100.00 | P | $133.51 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$178.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $100.00 | P | $133.51 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$178.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $100.00 | P | $133.51 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$178.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $100.00 | P | $133.51 |
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 |
Erickson Advantage Champion (HMO-POS SNP)
|
$189.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$85.00 | $245.00 | P | $120.20 |
Browse Plan Formulary |
Erickson Advantage Signature with Drugs (HMO-POS)
|
$189.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$85.00 | $245.00 | P | $120.20 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$192.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $112.50 | P | $120.63 |
Browse Plan Formulary |
Alliance Medicare PPO (PPO)
|
$210.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | P | $120.63 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$283.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P | $135.02 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$283.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P | $135.02 |
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)
|
$283.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P | $135.02 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$283.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P | $135.02 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$283.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | P | $135.02 |
Browse Plan Formulary |