ERAXIS 100mg/30mL 30 mL in 1 VIAL, SINGLE-USE (30 mL in 1 VIAL, SINGLE-U ) (NDC: 00049011628)
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 |
AARP MedicareComplete Mosaic (HMO)
|
$0.00 |
$150* | No additional gap coverage, only the Donut Hole Discount | 5* |
Specialty Tier |
33% | 33% | None | $187.03 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$260* | No additional gap coverage, only the Donut Hole Discount | 5* |
Specialty Tier |
33% | 33% | None | $187.03 |
Browse Plan Formulary |
Aetna Better Health FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
0% | 0% | None | $184.41 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $193.90 |
Browse Plan Formulary |
Affinity Medicare Passport Essentials (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $184.11 |
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 |
AgeWell New York FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
0% | 0% | None | $184.66 |
Browse Plan Formulary |
CenterLight Healthcare FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
0% | 0% | None | $182.59 |
Browse Plan Formulary |
Easy Choice Diamond Rewards (HMO SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$90.00 | $180.00 | None | $182.26 |
Browse Plan Formulary |
Easy Choice Rewards (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$85.00 | $170.00 | None | $182.26 |
Browse Plan Formulary |
Fidelis Fully Integrated Dual Advantage (FIDA) (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
0% | n/a | None | $183.55 |
Browse Plan Formulary |
Fidelis Medicare $0 Premium (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $200.80 |
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 |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | 33% | None | $183.55 |
Browse Plan Formulary |
Healthfirst AbsoluteCare FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
0% | 0% | None | $183.55 |
Browse Plan Formulary |
HealthPlus Amerigroup FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
0% | 0% | P | $187.91 |
Browse Plan Formulary |
Humana Gold Plus H3533-017 (HMO)
|
$0.00 |
$320 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $187.43 |
Browse Plan Formulary |
Liberty Health Advantage Preferred Choice (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$75.00 | $225.00 | P | $188.34 |
Browse Plan Formulary |
MetroPlus FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
0% | 0% | None | $193.95 |
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 |
North Shore-LIJ FIDA LiveWell (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
0% | 0% | None | $183.55 |
Browse Plan Formulary |
Touchstone Health Medicare Freedom (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$80.00 | $200.00 | P | $191.21 |
Browse Plan Formulary |
Touchstone Health Medicare Power (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$80.00 | $200.00 | P | $191.21 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (Regional PPO)
|
$0.00 |
$225* | No additional gap coverage, only the Donut Hole Discount | 5* |
Specialty Tier |
33% | 33% | None | $189.39 |
Browse Plan Formulary |
Fidelis Long Term Care Advantage (HMO SNP)
|
$3.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $183.55 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H3533-004 (HMO SNP)
|
$28.70 |
$125 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $187.43 |
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 |
AARP MedicareComplete Plan 1 (HMO)
|
$29.00 |
$230* | No additional gap coverage, only the Donut Hole Discount | 5* |
Specialty Tier |
33% | 33% | None | $187.03 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$30.30 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $189.39 |
Browse Plan Formulary |
LiveWell (HMO)
|
$32.90 |
$250 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $184.66 |
Browse Plan Formulary |
Fidelis Dual Advantage (HMO SNP)
|
$33.10 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $200.80 |
Browse Plan Formulary |
Healthfirst Increased Benefits Plan (HMO)
|
$34.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $183.55 |
Browse Plan Formulary |
Healthfirst Mount Sinai Select (HMO)
|
$34.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Specialty Tier |
33% | 33% | None | $194.71 |
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 Dual Advantage Flex (HMO SNP)
|
$35.40 |
$320 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | n/a | None | $183.55 |
Browse Plan Formulary |
Healthfirst AssuredCare (HMO SNP)
|
$36.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $183.55 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO SNP)
|
$36.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | None | $183.55 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO SNP)
|
$36.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | None | $183.55 |
Browse Plan Formulary |
Affinity Medicare Solutions (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $184.11 |
Browse Plan Formulary |
Affinity Medicare Ultimate (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $184.11 |
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 |
Amida Care Live Life Advantage (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
25% | 25% | None | $187.86 |
Browse Plan Formulary |
Amida Care True Life Advantage (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | None | $187.86 |
Browse Plan Formulary |
ArchCare Advantage (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $198.83 |
Browse Plan Formulary |
BeWell (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $184.66 |
Browse Plan Formulary |
CareWell (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $184.66 |
Browse Plan Formulary |
FeelWell (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $184.66 |
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 Medicaid Advantage Plus (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $200.80 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
|
$36.90 |
$240 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $183.55 |
Browse Plan Formulary |
Liberty Health Advantage Dual Power (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | P | $188.34 |
Browse Plan Formulary |
MetroPlus Advantage Plan (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $193.95 |
Browse Plan Formulary |
Touchstone Health Medicare Total (HMO)
|
$36.90 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$80.00 | $200.00 | P | $191.21 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
$0.00 | $0.00 | None | $189.39 |
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 |
Affinity Medicare Passport Select (HMO)
|
$46.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $184.11 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$97.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $193.90 |
Browse Plan Formulary |
MetroPlus Platinum (HMO)
|
$101.10 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $193.95 |
Browse Plan Formulary |
MetroPlus Select Plan (HMO SNP)
|
$123.30 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $193.95 |
Browse Plan Formulary |
Affinity Medicare Passport Elite (HMO)
|
$126.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $184.11 |
Browse Plan Formulary |
Aetna Medicare Select Plus Plan (PPO)
|
$139.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $184.43 |
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 |
MetroPlus Medicare Partnership in Care Plan (HMO SNP)
|
$244.20 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $193.95 |
Browse Plan Formulary |
HumanaChoice H5970-013 (PPO)
|
$323.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $187.43 |
Browse Plan Formulary |