Fondaparinux Sodium 2.5mg/0.5mL 2 SYRINGES per CARTON / 0.5 mL in 1 SYRINGE [Arixtra] (2 SYRINGE in 1 CARTON / 0 ) (NDC: 55111067802)
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 Choice Plan 2 (Regional PPO)
|
$0.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $55.15 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
50% | 50% | None | $86.43 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$90.00 | $270.00 | Q:15 /30Days | $97.87 |
Browse Plan Formulary |
Amerivantage Specialty + Rx (HMO SNP)
|
$0.00 |
$320 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$70.00 | $210.00 | Q:15 /30Days | $97.87 |
Browse Plan Formulary |
AvMed Medicare Choice (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$7.00 | $21.00 | Q:21 /60Days | $87.58 |
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 HMO LifeTime (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$5.00 | $15.00 | Q:15 /90Days | $54.92 |
Browse Plan Formulary |
BlueMedicare HMO MyTime (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$0.00 | $0.00 | Q:15 /90Days | $54.32 |
Browse Plan Formulary |
CareDirect (HMO SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 4 |
Non-Preferred Brand |
$50.00 | $140.00 | Q:14 /30Days | $75.92 |
Browse Plan Formulary |
CareHeart (HMO SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 4 |
Non-Preferred Brand |
$45.00 | $125.00 | Q:14 /30Days | $75.92 |
Browse Plan Formulary |
CareOne (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 4 |
Non-Preferred Brand |
$50.00 | $140.00 | Q:14 /30Days | $75.92 |
Browse Plan Formulary |
Coventry Summit Ideal (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Non-Preferred Brand |
50% | 50% | None | $85.03 |
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 |
Coventry Vista Ideal (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
50% | 50% | None | $76.45 |
Browse Plan Formulary |
HealthSun HealthAdvantage Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$0.00 | n/a | None | $80.95 |
Browse Plan Formulary |
Humana Gold Plus - Diabetes (HMO SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 4 |
Non-Preferred Brand |
$50.00 | $140.00 | Q:14 /30Days | $75.92 |
Browse Plan Formulary |
Humana Gold Plus - Heart (HMO SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 4 |
Non-Preferred Brand |
$50.00 | $140.00 | Q:14 /30Days | $75.92 |
Browse Plan Formulary |
Humana Gold Plus H1036-065C (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 4 |
Non-Preferred Brand |
$50.00 | $140.00 | Q:14 /30Days | $75.92 |
Browse Plan Formulary |
Humana Gold Plus H1036-237 (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:14 /30Days | $75.92 |
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 H1036-237 (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:14 /30Days | $75.92 |
Browse Plan Formulary |
HumanaChoice R5826-074 (Regional PPO)
|
$0.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:14 /30Days | $75.92 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Non-Preferred Brand |
$89.00 | $257.00 | None | $45.33 |
Browse Plan Formulary |
PHP (HMO SNP)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
25% | n/a | P Q:24 /24Days | $92.18 |
Browse Plan Formulary |
Preferred Choice Broward (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Non-Preferred Brand |
$40.00 | $110.00 | None | $45.33 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:16 /30Days | $96.78 |
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 |
WellCare Essential (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:16 /30Days | $96.91 |
Browse Plan Formulary |
WellCare Value (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | Q:16 /30Days | $96.59 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-103A (HMO SNP)
|
$13.30 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:14 /30Days | $75.92 |
Browse Plan Formulary |
CareNeeds (HMO SNP)
|
$15.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:14 /30Days | $75.92 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$17.70 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:16 /30Days | $97.02 |
Browse Plan Formulary |
WellCare Liberty (HMO SNP)
|
$18.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:16 /30Days | $97.02 |
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 |
WellCare Select (HMO SNP)
|
$19.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:16 /30Days | $96.88 |
Browse Plan Formulary |
BlueMedicare Regional PPO (Regional PPO)
|
$20.20 |
$100 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$28.00 | $84.00 | Q:15 /90Days | $55.72 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax Plus (HMO-POS SNP)
|
$24.30 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Non-Preferred Brand |
25% | 25% | None | $51.94 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$24.30 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $51.77 |
Browse Plan Formulary |
Preferred Medicare Assist (HMO-POS SNP)
|
$24.40 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Non-Preferred Brand |
25% | 25% | None | $51.94 |
Browse Plan Formulary |
Coventry Summit Maximum (HMO SNP)
|
$24.60 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Non-Preferred Brand |
50% | 50% | None | $74.76 |
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 |
Molina Medicare Options Plus (HMO SNP)
|
$24.80 |
$320* | Yes, but No Gap Coverage for this drug. | 1* |
Generic |
$0.00 | $0.00 | None | $87.58 |
Browse Plan Formulary |
HealthSun MediMax (HMO)
|
$25.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
25% | n/a | None | $81.80 |
Browse Plan Formulary |
Sunshine Health Advantage (HMO SNP)
|
$25.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Injectable Drugs |
$95.00 | $95.00 | None | $94.20 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP (Regional PPO SNP)
|
$25.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | None | $55.15 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$35.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
50% | 50% | None | $86.85 |
Browse Plan Formulary |
HumanaChoice R5826-005 (Regional PPO)
|
$39.40 |
$100 | Yes, this drug has Gap Coverage. | 4 |
Non-Preferred Brand |
$85.00 | $245.00 | Q:14 /30Days | $75.92 |
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 |
HumanaChoice H5415-056 (PPO)
|
$43.00 |
$0 | Yes, this drug has Gap Coverage. | 4 |
Non-Preferred Brand |
$85.00 | $245.00 | Q:14 /30Days | $75.92 |
Browse Plan Formulary |
Humana Gold Choice H8145-061 (PFFS)
|
$101.00 |
$0 | Yes, this drug has Gap Coverage. | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:14 /30Days | $75.92 |
Browse Plan Formulary |
BlueMedicare PPO (PPO)
|
$127.10 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$5.00 | $15.00 | Q:15 /90Days | $55.14 |
Browse Plan Formulary |
Aetna Medicare Select Plus Plan (HMO)
|
$139.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
50% | 50% | None | $86.85 |
Browse Plan Formulary |
Aetna Medicare Select Plus Plan (PPO)
|
$139.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
50% | 50% | None | $86.68 |
Browse Plan Formulary |