MITOMYCIN 20 MG VIAL (NDC: 16729024711)
2017 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 |
$400 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | n/a | None | $531.52 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | n/a | None | $531.52 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | n/a | None | $530.01 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | n/a | None | $530.01 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | n/a | None | $530.01 |
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 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | P | $288.92 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | P | $528.09 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | P | $528.09 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | P | $460.73 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | P | $528.09 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | P | $528.09 |
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)
|
$18.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | P | $288.92 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | P | $528.09 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | P | $528.09 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | P | $460.73 |
Browse Plan Formulary |
HumanaChoice R5826-006 (Regional PPO)
|
$25.50 |
$400 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
25% | 25% | P | $762.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$30.50 |
$400 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | n/a | None | $531.52 |
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)
|
$30.50 |
$400 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | n/a | None | $531.52 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$30.50 |
$400 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | n/a | None | $531.63 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$30.50 |
$400 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | n/a | None | $531.63 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$30.50 |
$400 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | n/a | None | $531.63 |
Browse Plan Formulary |
McLaren Advantage Sapphire (HMO)
|
$73.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 4 |
Specialty Tier |
29% | n/a | None | $532.33 |
Browse Plan Formulary |
McLaren Advantage Sapphire (HMO)
|
$73.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 4 |
Specialty Tier |
29% | n/a | None | $541.17 |
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 Value (HMO-POS)
|
$78.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | P | $531.57 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$86.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | n/a | None | $531.52 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$86.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | n/a | None | $531.52 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$86.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | n/a | None | $531.63 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$86.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | n/a | None | $531.63 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$86.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | n/a | None | $531.63 |
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 |
PriorityMedicare Merit (PPO)
|
$87.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | n/a | P | $288.90 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$87.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | n/a | P | $531.57 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$87.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | n/a | P | $531.57 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$87.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | n/a | P | $531.57 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$87.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | n/a | P | $460.71 |
Browse Plan Formulary |
Humana Gold Choice H8145-006 (PFFS)
|
$97.00 |
$400 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $700.19 |
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 |
McLaren Advantage Diamond (HMO)
|
$132.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 4 |
Specialty Tier |
29% | n/a | None | $532.33 |
Browse Plan Formulary |
McLaren Advantage Diamond (HMO)
|
$132.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 4 |
Specialty Tier |
29% | n/a | None | $541.17 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$139.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | n/a | None | $530.01 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$139.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | n/a | None | $531.52 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$139.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | n/a | None | $531.52 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$139.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | n/a | None | $530.01 |
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)
|
$139.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | n/a | None | $530.01 |
Browse Plan Formulary |
McLaren Advantage Diamond + (HMO)
|
$160.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 4 |
Specialty Tier |
29% | n/a | None | $532.33 |
Browse Plan Formulary |
McLaren Advantage Diamond + (HMO)
|
$160.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 4 |
Specialty Tier |
29% | n/a | None | $541.17 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$160.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$8.00 | n/a | P | $531.57 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$174.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | n/a | P | $288.90 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$174.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | n/a | P | $531.57 |
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)
|
$174.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | n/a | P | $531.57 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$174.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | n/a | P | $531.57 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$174.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | n/a | P | $460.71 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$181.00 |
$105 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | n/a | None | $531.52 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$181.00 |
$105 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | n/a | None | $531.52 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$181.00 |
$105 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | n/a | None | $531.63 |
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 |
Medicare Plus Blue PPO Signature (PPO)
|
$181.00 |
$105 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | n/a | None | $531.63 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$181.00 |
$105 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | n/a | None | $531.63 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$264.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | n/a | None | $531.52 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$264.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | n/a | None | $531.52 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$264.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | n/a | None | $531.63 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$264.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | n/a | None | $531.63 |
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 |
Medicare Plus Blue PPO Assure (PPO)
|
$264.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | n/a | None | $531.63 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$280.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | n/a | None | $530.01 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$280.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | n/a | None | $530.01 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$280.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | n/a | None | $530.01 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$280.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | n/a | None | $531.52 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$280.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
45% | n/a | None | $531.52 |
Browse Plan Formulary |