FONDAPARINUX 10 MG/0.8 ML SYRINGE [Arixtra] (4 mls ) (NDC: 67457058508)
2022 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 |
AARP Medicare Advantage (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $2,836.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Walgreens (PPO)
|
$0.00 |
$345 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
27% | n/a | None | $2,759.76 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Plus Plan (PPO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | None | $2,610.24 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | None | $3,030.48 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:24 /30Days | $1,197.60 |
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 |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:24 /30Days | $1,098.96 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:24 /30Days | $1,070.16 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:24 /30Days | $1,079.04 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:24 /30Days | $1,097.76 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:24 /30Days | $1,269.36 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:24 /30Days | $1,065.36 |
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 |
Ascension Complete Seton Access (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $2,605.44 |
Browse Plan Formulary |
Ascension Complete Seton Access Plus (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $2,605.44 |
Browse Plan Formulary |
Ascension Complete Seton Reward (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $2,605.44 |
Browse Plan Formulary |
Ascension Complete Seton Secure (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $2,605.44 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Choice Plus (PPO)
|
$0.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | Q:24 /90Days | $1,512.96 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Classic (PPO)
|
$0.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | Q:24 /90Days | $1,564.56 |
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 |
Blue Cross Medicare Advantage Value (HMO)
|
$0.00 |
$100 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
31% | n/a | Q:24 /90Days | $1,564.56 |
Browse Plan Formulary |
BSW SeniorCare Advantage Select Rx (HMO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | n/a | Q:28 /90Days | $1,559.28 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Imperial Insurance Company Traditional (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:11 /30Days | $1,473.84 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Imperial Insurance Traditional Plus (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | Q:11 /30Days | $1,473.84 |
Browse Plan Formulary |
Imperial Insurance Value (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
5 |
Specialty Tier |
33% | n/a | Q:11 /30Days | $1,473.84 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
UnitedHealthcare Chronic Complete (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | None | $2,857.68 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
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 |
UnitedHealthcare Dual Complete Choice (Regional PPO D-SNP)
|
$0.00 |
$480 |
No |
5 |
Tier 5 |
$0.00 | $0.00 | None | $2,820.24 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | None | $906.24 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | None | $2,064.00 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | None | $1,150.08 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | None | $1,372.32 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | None | $1,729.92 |
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 |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $906.24 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $2,064.00 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,150.08 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,372.32 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,729.92 |
Browse Plan Formulary |
Wellcare No Premium Rx Plus Open (PPO)
|
$0.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | None | $1,163.28 |
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 TexanPlus No Premium (HMO)
|
$0.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
29% | n/a | None | $1,729.92 |
Browse Plan Formulary |
UnitedHealthcare Medicare Silver (Regional PPO C-SNP)
|
$3.70 |
$480 |
No |
5 |
Tier 5 |
25% | 25% | None | $2,820.24 |
Browse Plan Formulary |
UnitedHealthcare Medicare Gold (Regional PPO C-SNP)
|
$10.80 |
$295 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | None | $2,820.24 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Complement Assist (HMO)
|
$14.90 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $2,266.08 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$15.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | None | $2,610.24 |
Browse Plan Formulary |
Aetna Medicare Dual Complete Plan (HMO D-SNP)
|
$18.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $2,943.12 |
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 |
Blue Cross Medicare Advantage Dual Care Plus (HMO D-SNP)
|
$18.80 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:24 /90Days | $1,732.08 |
Browse Plan Formulary |
Wellcare Low Premium Open (PPO)
|
$20.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
29% | n/a | None | $1,729.92 |
Browse Plan Formulary |
Wellcare Assist (HMO)
|
$20.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $1,566.00 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Focus (HMO D-SNP)
|
$21.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | None | $2,857.68 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | Q:24 /30Days | $1,197.60 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | Q:24 /30Days | $1,065.36 |
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 |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | Q:24 /30Days | $1,098.96 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | Q:24 /30Days | $1,070.16 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | Q:24 /30Days | $1,079.04 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | Q:24 /30Days | $1,097.76 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | Q:24 /30Days | $1,269.36 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | Q:24 /30Days | $1,065.36 |
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 |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | Q:24 /30Days | $1,098.96 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | Q:24 /30Days | $1,070.16 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | Q:24 /30Days | $1,079.04 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | Q:24 /30Days | $1,097.76 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | Q:24 /30Days | $1,269.36 |
Browse Plan Formulary |
Amerivantage ESRD Care (HMO-POS C-SNP)
|
$25.10 |
$100 |
Few Generics |
5 |
Specialty Tier |
31% | n/a | Q:24 /30Days | $1,070.88 |
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 |
Imperial Insurance Company Dual (HMO D-SNP)
|
$25.10 |
$480 |
Many Generics, Some Brands |
5 |
Specialty Tier |
25% | n/a | Q:11 /30Days | $1,489.44 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | None | $2,857.68 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | None | $2,850.96 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | None | $2,857.68 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO I-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | None | $2,837.28 |
Browse Plan Formulary |
Wellcare Dual Access Harmony (HMO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $2,276.40 |
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 Dual Access Open (PPO D-SNP)
|
$25.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $1,566.00 |
Browse Plan Formulary |
BSW SeniorCare Advantage Basic (PPO)
|
$37.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | Q:28 /90Days | $1,559.28 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Advantage Choice (Regional PPO)
|
$49.00 |
$395 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
26% | n/a | None | $2,820.24 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Blue Cross Medicare Advantage Choice Premier (PPO)
|
$90.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | Q:24 /90Days | $1,512.96 |
Browse Plan Formulary |
BSW SeniorCare Advantage Platinum (PPO)
|
$140.00 |
$50 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
32% | n/a | Q:28 /90Days | $1,559.28 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BSW SeniorCare Advantage Preferred Rx (HMO)
|
$145.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | Q:28 /90Days | $1,559.28 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
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 |
Blue Cross Medicare Advantage Flex (PPO)
|
$215.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | Q:24 /90Days | $1,949.76 |
Browse Plan Formulary |
BSW SeniorCare Advantage Premium Rx (HMO)
|
$255.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | Q:28 /90Days | $1,559.28 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |