AMIFOSTINE 50mg/mL 3 VIAL, SINGLE-USE per CARTON / 10 mL in 1 VIAL, SINGLE-USE (3 VIAL, SINGLE-USE in 1 C ) (NDC: 47335058142)
2016 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 |
Aetna Better Health Premier Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Generic Drugs |
0% | 0% | None | $1,495.88 |
Browse Plan Formulary |
AmeriHealth Caritas VIP Care PLUS (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Generic Drugs |
0% | 0% | P | $1,306.62 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $1,422.62 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $1,422.62 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $1,422.62 |
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 Basic (HMO-POS)
|
$0.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $1,422.62 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $1,422.62 |
Browse Plan Formulary |
Fidelis SecureLife (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Generic Drugs |
0% | 0% | None | $1,385.76 |
Browse Plan Formulary |
HAP Midwest MI Health Link (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Generic Drugs |
0% | n/a | None | $1,405.72 |
Browse Plan Formulary |
Harbor Medicare (HMO)
|
$0.00 |
$240 | to be determined | 2 |
Generic |
$20.00 | $40.00 | P | $1,322.10 |
Browse Plan Formulary |
HealthPlus MedicarePlus Option 0 (HMO)
|
$0.00 |
$360 | to be determined | 2 |
Generic |
$11.00 | $27.50 | None | $1,318.39 |
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 |
Meridian Prime (HMO)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
$0.00 | $0.00 | None | $1,131.79 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Brand Drugs |
0% | 0% | P | $1,420.32 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $1,385.67 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $1,385.67 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $1,385.67 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $1,385.67 |
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 Key (HMO-POS)
|
$0.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $1,385.67 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $1,385.67 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $1,385.67 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $1,385.67 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $1,385.67 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $1,385.67 |
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)
|
$20.50 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $1,422.62 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$20.50 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $1,422.62 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$20.50 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $1,422.62 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$20.50 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $1,422.62 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$20.50 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $1,422.62 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$33.00 |
$360 | to be determined | 5 |
Specialty Tier |
25% | n/a | P | $1,424.91 |
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 Midwest Health Plan (HMO SNP)
|
$33.50 |
$360 | to be determined | 1 |
Generic |
$7.00 | n/a | None | $1,405.72 |
Browse Plan Formulary |
Meridian Advantage Plan of Michigan (HMO SNP)
|
$33.50 |
$360 | to be determined | 1 |
Tier 1 |
$0.00 | $0.00 | None | $1,131.79 |
Browse Plan Formulary |
BCN Advantage HMO ConnectedCare (HMO)
|
$47.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $1,422.62 |
Browse Plan Formulary |
Harbor Medicare Select (HMO)
|
$47.00 |
$0 | to be determined | 2 |
Generic |
$10.00 | $20.00 | P | $1,322.10 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$59.00 |
$0 | to be determined | 2 |
Generic |
$11.00 | $27.50 | None | $1,320.43 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$66.00 |
$75 | to be determined | 5 |
Tier 5 |
31% | n/a | None | $1,385.67 |
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)
|
$79.00 |
$200* | to be determined | 2* |
Generic |
$15.00 | $37.50 | None | $1,320.43 |
Browse Plan Formulary |
McLaren Advantage Sapphire (HMO)
|
$81.00 |
$150 | to be determined | 4 |
Specialty Tier |
29% | n/a | None | $1,341.55 |
Browse Plan Formulary |
McLaren Advantage Sapphire (HMO)
|
$81.00 |
$150 | to be determined | 4 |
Specialty Tier |
29% | n/a | None | $1,341.55 |
Browse Plan Formulary |
Humana Gold Plus H8908-001 (HMO)
|
$89.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | P | $1,768.96 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75 | to be determined | 5 |
Tier 5 |
31% | n/a | None | $1,385.67 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75 | to be determined | 5 |
Tier 5 |
31% | n/a | None | $1,385.67 |
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 Merit (PPO)
|
$95.00 |
$75 | to be determined | 5 |
Tier 5 |
31% | n/a | None | $1,385.67 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75 | to be determined | 5 |
Tier 5 |
31% | n/a | None | $1,385.67 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75 | to be determined | 5 |
Tier 5 |
31% | n/a | None | $1,385.67 |
Browse Plan Formulary |
HealthPlus MedicarePlus Option 1 (HMO)
|
$98.00 |
$100* | to be determined | 2* |
Generic |
$15.00 | $37.50 | None | $1,318.39 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$106.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $1,422.62 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$106.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $1,422.62 |
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)
|
$106.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $1,422.62 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$106.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $1,422.62 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$106.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $1,422.62 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$109.00 |
$100* | to be determined | 2* |
Generic |
$15.00 | $37.50 | None | $1,320.43 |
Browse Plan Formulary |
McLaren Advantage Diamond (HMO)
|
$117.00 |
$150 | to be determined | 4 |
Specialty Tier |
29% | n/a | None | $1,341.55 |
Browse Plan Formulary |
McLaren Advantage Diamond (HMO)
|
$117.00 |
$150 | to be determined | 4 |
Specialty Tier |
29% | n/a | None | $1,341.55 |
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 R5826-006 (Regional PPO)
|
$121.00 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | P | $1,768.96 |
Browse Plan Formulary |
Alliance Medicare PPO (PPO)
|
$126.00 |
$0 | to be determined | 2 |
Generic |
$15.00 | $37.50 | None | $1,320.43 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$146.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,385.67 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$154.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $1,422.62 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$154.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $1,422.62 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$154.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $1,422.62 |
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)
|
$154.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $1,422.62 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$154.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $1,422.62 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$169.00 |
$100 | to be determined | 5 |
Specialty Tier |
30% | n/a | None | $1,422.62 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$169.00 |
$100 | to be determined | 5 |
Specialty Tier |
30% | n/a | None | $1,422.62 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$169.00 |
$100 | to be determined | 5 |
Specialty Tier |
30% | n/a | None | $1,422.62 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$169.00 |
$100 | to be determined | 5 |
Specialty Tier |
30% | n/a | None | $1,422.62 |
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)
|
$169.00 |
$100 | to be determined | 5 |
Specialty Tier |
30% | n/a | None | $1,422.62 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$193.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,385.67 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$193.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,385.67 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$193.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,385.67 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$193.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,385.67 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$193.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,385.67 |
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)
|
$210.00 |
$150* | to be determined | 2* |
Generic |
$10.00 | $25.00 | None | $1,320.43 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$220.00 |
$50* | to be determined | 2* |
Generic |
$10.00 | $25.00 | None | $1,320.43 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$283.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $1,422.62 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$283.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $1,422.62 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$283.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $1,422.62 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$283.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $1,422.62 |
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)
|
$283.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $1,422.62 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$294.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $1,422.62 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$294.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $1,422.62 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$294.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $1,422.62 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$294.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $1,422.62 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$294.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $1,422.62 |
Browse Plan Formulary |