Fondaparinux Sodium 5mg/4mL 2 SYRINGES per CARTON / 0.4 mL in 1 SYRINGE [Arixtra] (2 SYRINGE in 1 CARTON ) (NDC: 55111067902)
2018 Medicare Prescription Drug Plan (MAPD) Information
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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 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $165.38 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $162.15 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $172.37 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $172.37 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $168.22 |
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 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | Q:12 /30Days | $100.36 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | Q:12 /30Days | $169.49 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | Q:12 /30Days | $163.53 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | Q:12 /30Days | $171.24 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | Q:12 /30Days | $170.83 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | Q:12 /30Days | $161.51 |
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 Option 1 (PPO)
|
$15.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | Q:12 /30Days | $100.36 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | Q:12 /30Days | $170.83 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | Q:12 /30Days | $161.51 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | Q:12 /30Days | $169.49 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | Q:12 /30Days | $163.53 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | Q:12 /30Days | $171.24 |
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 R3887-002 (Regional PPO)
|
$20.00 |
$405 |
to be determined |
5 |
Specialty Tier |
25% | n/a | Q:12 /30Days | $135.74 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$29.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $172.37 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$29.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $172.37 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$29.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $172.37 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$29.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $168.22 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$29.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $165.45 |
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 Option 1 (HMO-POS)
|
$45.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | Q:12 /30Days | $100.36 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$63.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | Q:12 /30Days | $169.49 |
Browse Plan Formulary |
HAP Senior Plus Option 2 (HMO-POS)
|
$85.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | Q:12 /30Days | $100.36 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$85.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | Q:12 /30Days | $161.51 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$85.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | Q:12 /30Days | $169.49 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$85.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | Q:12 /30Days | $163.53 |
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)
|
$85.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | Q:12 /30Days | $171.24 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$85.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | Q:12 /30Days | $170.83 |
Browse Plan Formulary |
Humana Gold Choice H8145-006 (PFFS)
|
$97.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | Q:12 /30Days | $135.74 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$104.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $172.37 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$104.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $168.22 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$104.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $165.45 |
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)
|
$104.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $172.37 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$104.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $172.37 |
Browse Plan Formulary |
HAP Senior Plus Option 2 (PPO)
|
$118.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | Q:12 /30Days | $100.36 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$152.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $172.37 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$152.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $172.37 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$152.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $168.22 |
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)
|
$152.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $165.38 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$152.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $162.15 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$155.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | Q:12 /30Days | $169.49 |
Browse Plan Formulary |
HAP Senior Plus Option 3 (HMO-POS)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:12 /30Days | $100.36 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$179.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | Q:12 /30Days | $171.24 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$179.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | Q:12 /30Days | $161.51 |
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 Select (PPO)
|
$179.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | Q:12 /30Days | $170.83 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$179.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | Q:12 /30Days | $169.49 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$179.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | Q:12 /30Days | $163.53 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$179.50 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $172.37 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$179.50 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $172.37 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$179.50 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $168.22 |
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)
|
$179.50 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $165.45 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$179.50 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $172.37 |
Browse Plan Formulary |
HAP Senior Plus Option 3 (PPO)
|
$190.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:12 /30Days | $100.36 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$301.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $172.37 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$301.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $168.22 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$301.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $165.38 |
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)
|
$301.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $162.15 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$301.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $172.37 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$312.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $165.45 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$312.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $172.37 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$312.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $172.37 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$312.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $172.37 |
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)
|
$312.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $168.22 |
Browse Plan Formulary |