PROGRAF 5MG/ML AMPULE (10 X 1 ML AMP) (NDC: 00469301601)
2011 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 (PPO)
![Email Prescription and/or Health Benefit details for AARP MedicareComplete Choice (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $245.00 | P | $1,475.70 |
Browse Plan Formulary |
AARP MedicareComplete Choice Plan 2 (Regional PPO)
![Email Prescription and/or Health Benefit details for AARP MedicareComplete Choice Plan 2 (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $245.00 | P | $1,475.70 |
Browse Plan Formulary |
AARP MedicareComplete Plus Plan 1 (HMO-POS)
![Email Prescription and/or Health Benefit details for AARP MedicareComplete Plus Plan 1 (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $245.00 | P | $1,475.70 |
Browse Plan Formulary |
Advantage (HMO)
![Email Prescription and/or Health Benefit details for Advantage (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$45.00 | n/a | P | $1,475.50 |
Browse Plan Formulary |
Advantage Health Florida (HMO SNP)
![Email Prescription and/or Health Benefit details for Advantage Health Florida (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$45.00 | n/a | P | $1,475.50 |
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 |
Advantage Silver (HMO)
![Email Prescription and/or Health Benefit details for Advantage Silver (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$45.00 | n/a | P | $1,475.50 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
![Email Prescription and/or Health Benefit details for Any, Any, Any Gold (PFFS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$45.00 | $120.00 | P | n/a |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
![Email Prescription and/or Health Benefit details for Any, Any, Any Platinum (PFFS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | n/a |
Browse Plan Formulary |
BlueMedicare HMO (HMO)
![Email Prescription and/or Health Benefit details for BlueMedicare HMO (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$130 |
to be determined |
3 |
Tier 3 |
$89.00 | $178.00 | P | $1,430.75 |
Browse Plan Formulary |
CareOne (HMO)
![Email Prescription and/or Health Benefit details for CareOne (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $230.00 | P | $1,410.38 |
Browse Plan Formulary |
CareOne Plus (HMO)
![Email Prescription and/or Health Benefit details for CareOne Plus (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $155.00 | P | n/a |
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 |
Citrus Total (HMO)
![Email Prescription and/or Health Benefit details for Citrus Total (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$69.00 | $192.00 | P | $1,445.14 |
Browse Plan Formulary |
e-Any, Any, Any Gold Direct (PFFS)
![Email Prescription and/or Health Benefit details for e-Any, Any, Any Gold Direct (PFFS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$45.00 | $120.00 | P | n/a |
Browse Plan Formulary |
e-Medicare Masterpiece Direct (HMO)
![Email Prescription and/or Health Benefit details for e-Medicare Masterpiece Direct (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$45.00 | $115.00 | P | n/a |
Browse Plan Formulary |
e-Medicare Masterpiece Premier Direct (HMO)
![Email Prescription and/or Health Benefit details for e-Medicare Masterpiece Premier Direct (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$20.00 | $50.00 | P | n/a |
Browse Plan Formulary |
Freedom Medicare Plan Rx (HMO)
![Email Prescription and/or Health Benefit details for Freedom Medicare Plan Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$60.00 | $120.00 | P | $1,418.87 |
Browse Plan Formulary |
Freedom Savings Plan Rx (HMO)
![Email Prescription and/or Health Benefit details for Freedom Savings Plan Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$65.00 | $130.00 | P | $1,418.87 |
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 |
Freedom VIP Care (HMO SNP)
![Email Prescription and/or Health Benefit details for Freedom VIP Care (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$60.00 | $120.00 | P | $1,418.87 |
Browse Plan Formulary |
Freedom VIP Care COPD (HMO SNP)
![Email Prescription and/or Health Benefit details for Freedom VIP Care COPD (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$60.00 | $120.00 | P | $1,418.87 |
Browse Plan Formulary |
Freedom VIP Savings (HMO SNP)
![Email Prescription and/or Health Benefit details for Freedom VIP Savings (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$60.00 | $120.00 | P | $1,418.87 |
Browse Plan Formulary |
Freedom VIP Savings COPD (HMO SNP)
![Email Prescription and/or Health Benefit details for Freedom VIP Savings COPD (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$60.00 | $120.00 | P | $1,418.87 |
Browse Plan Formulary |
Humana Gold Plus H1036-025 (HMO)
![Email Prescription and/or Health Benefit details for Humana Gold Plus H1036-025 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $155.00 | P | $1,410.38 |
Browse Plan Formulary |
Humana Gold Plus H1036-141 (HMO)
![Email Prescription and/or Health Benefit details for Humana Gold Plus H1036-141 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $230.00 | P | n/a |
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 Masterpiece (HMO)
![Email Prescription and/or Health Benefit details for Medicare Masterpiece (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$39.00 | $100.00 | P | $1,421.45 |
Browse Plan Formulary |
Medicare Masterpiece (PPO)
![Email Prescription and/or Health Benefit details for Medicare Masterpiece (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$45.00 | $120.00 | P | $1,421.45 |
Browse Plan Formulary |
Medicare Masterpiece Premier (HMO)
![Email Prescription and/or Health Benefit details for Medicare Masterpiece Premier (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$20.00 | $50.00 | P | $1,421.45 |
Browse Plan Formulary |
Medicare Masterpiece Premier SNP - COPD (HMO SNP)
![Email Prescription and/or Health Benefit details for Medicare Masterpiece Premier SNP - COPD (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$20.00 | $50.00 | P | $1,421.45 |
Browse Plan Formulary |
Medicare Masterpiece Premier SNP - Dementia (HMO SNP)
![Email Prescription and/or Health Benefit details for Medicare Masterpiece Premier SNP - Dementia (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$20.00 | $50.00 | P | $1,421.45 |
Browse Plan Formulary |
Medicare Masterpiece Premier SNP - Diabetes (HMO SNP)
![Email Prescription and/or Health Benefit details for Medicare Masterpiece Premier SNP - Diabetes (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$20.00 | $50.00 | P | $1,421.45 |
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 Masterpiece Premier SNP - Institutional (HMO SNP)
![Email Prescription and/or Health Benefit details for Medicare Masterpiece Premier SNP - Institutional (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | P | $1,421.45 |
Browse Plan Formulary |
Optimum Gold Plan (HMO-POS)
![Email Prescription and/or Health Benefit details for Optimum Gold Plan (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$69.00 | $138.00 | P | $1,418.87 |
Browse Plan Formulary |
Optimum Platinum Plan (HMO)
![Email Prescription and/or Health Benefit details for Optimum Platinum Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$69.00 | $138.00 | P | $1,418.87 |
Browse Plan Formulary |
Optimum Platinum Plus (HMO-POS)
![Email Prescription and/or Health Benefit details for Optimum Platinum Plus (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$50.00 | $100.00 | P | n/a |
Browse Plan Formulary |
Preferred Care Partners Preferred Gold Option (HMO)
![Email Prescription and/or Health Benefit details for Preferred Care Partners Preferred Gold Option (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$50.00 | $100.00 | None | n/a |
Browse Plan Formulary |
Preferred Care Partners Preferred PremiumAdvantage (HMO-POS)
![Email Prescription and/or Health Benefit details for Preferred Care Partners Preferred PremiumAdvantage (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$60.00 | $120.00 | None | $1,427.29 |
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 |
PUP Easy (HMO)
![Email Prescription and/or Health Benefit details for PUP Easy (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $240.00 | P | $1,475.70 |
Browse Plan Formulary |
PUP Rewards (HMO)
![Email Prescription and/or Health Benefit details for PUP Rewards (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$90.00 | $270.00 | P | $1,475.70 |
Browse Plan Formulary |
Value One Florida (HMO SNP)
![Email Prescription and/or Health Benefit details for Value One Florida (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | P | $1,475.50 |
Browse Plan Formulary |
WellCare Choice (HMO-POS)
![Email Prescription and/or Health Benefit details for WellCare Choice (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.00 | P | $1,454.38 |
Browse Plan Formulary |
WellCare Dividend (HMO)
![Email Prescription and/or Health Benefit details for WellCare Dividend (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$39.00 | $97.00 | P | $1,454.38 |
Browse Plan Formulary |
WellCare Value (HMO-POS)
![Email Prescription and/or Health Benefit details for WellCare Value (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $1,454.38 |
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 |
Medicare Masterpiece Plus (HMO-POS)
![Email Prescription and/or Health Benefit details for Medicare Masterpiece Plus (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$13.90 |
$0 |
to be determined |
3 |
Tier 3 |
$45.00 | $110.00 | P | $1,421.45 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Value Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$18.40 |
$0 |
to be determined |
4 |
Tier 4: Non-Preferred Brand Drugs |
$85.00 | $170.00 | P | $1,425.00 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
![Email Prescription and/or Health Benefit details for WellCare Access (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$20.30 |
$310 |
to be determined |
2 |
Tier 2 |
$45.00 | $112.00 | P | $1,454.38 |
Browse Plan Formulary |
HumanaChoice R5826-074 (Regional PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice R5826-074 (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$20.80 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | P | $1,410.38 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-102 (HMO SNP)
![Email Prescription and/or Health Benefit details for Humana Gold Plus SNP-DE H1036-102 (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$23.30 |
$310 |
to be determined |
4 |
Tier 4 |
$85.00 | $245.00 | P | $1,410.38 |
Browse Plan Formulary |
WellCare Select (HMO-POS SNP)
![Email Prescription and/or Health Benefit details for WellCare Select (HMO-POS SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$23.30 |
$310 |
to be determined |
2 |
Tier 2 |
$44.00 | $110.00 | P | $1,454.38 |
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 |
CareNeeds (HMO SNP)
![Email Prescription and/or Health Benefit details for CareNeeds (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$25.40 |
$310 |
to be determined |
4 |
Tier 4 |
$78.00 | $224.00 | P | $1,410.38 |
Browse Plan Formulary |
CareNeeds Plus (HMO SNP)
![Email Prescription and/or Health Benefit details for CareNeeds Plus (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$25.40 |
$310 |
to be determined |
4 |
Tier 4 |
$80.00 | $230.00 | P | $1,410.38 |
Browse Plan Formulary |
Evercare Plan IP (PPO SNP)
![Email Prescription and/or Health Benefit details for Evercare Plan IP (PPO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$25.40 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | P | $1,475.70 |
Browse Plan Formulary |
Humana Gold Choice H8145-061 (PFFS)
![Email Prescription and/or Health Benefit details for Humana Gold Choice H8145-061 (PFFS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$26.10 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | n/a |
Browse Plan Formulary |
HumanaChoice R5826-005 (Regional PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice R5826-005 (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$28.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,410.38 |
Browse Plan Formulary |
BlueMedicare Regional PPO (Regional PPO)
![Email Prescription and/or Health Benefit details for BlueMedicare Regional PPO (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$31.20 |
$150 |
to be determined |
3 |
Tier 3 |
$89.00 | $178.00 | P | $1,430.75 |
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 |
Aetna Medicare Standard Plan (PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Standard Plan (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$37.80 |
$0 |
to be determined |
4 |
Tier 4: Non-Preferred Brand Drugs |
$85.00 | $170.00 | P | $1,425.00 |
Browse Plan Formulary |
BlueMedicare PPO (PPO)
![Email Prescription and/or Health Benefit details for BlueMedicare PPO (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$39.40 |
$150 |
to be determined |
3 |
Tier 3 |
$89.00 | $178.00 | P | $1,430.75 |
Browse Plan Formulary |