PROGRAF 5MG/ML AMPULE (10 X 1 ML AMP) (NDC: 00469301601)
2012 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 SecureHorizons (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$92.00 | $266.00 | P | $1,478.43 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$92.00 | $266.00 | P | $1,478.43 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$95.00 | $190.00 | P | $1,484.74 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$95.00 | $190.00 | P | $1,484.74 |
Browse Plan Formulary |
Anthem Medicare Preferred Standard (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,219.37 |
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 |
Blue Cross Senior Secure Plan I (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,219.37 |
Browse Plan Formulary |
Blue Cross Senior Secure Plan I (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,219.37 |
Browse Plan Formulary |
Brand New Day (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$40.00 | $80.00 | P | $1,460.97 |
Browse Plan Formulary |
Brand New Day (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$40.00 | $80.00 | P | $1,460.97 |
Browse Plan Formulary |
Care1st AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $1,439.31 |
Browse Plan Formulary |
Care1st AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $1,439.31 |
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 |
Care1st TotalAdvantage Plan (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $1,439.31 |
Browse Plan Formulary |
Care1st TotalAdvantage Plan (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $1,439.31 |
Browse Plan Formulary |
CareMore Breathe (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$85.00 | $212.50 | P | $1,439.00 |
Browse Plan Formulary |
CareMore Breathe (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$85.00 | $212.50 | P | $1,439.00 |
Browse Plan Formulary |
CareMore Connect (HMO SNP)
|
$0.00 |
$320 |
to be determined |
4 |
Tier 4 |
25% | 25% | P | $1,439.00 |
Browse Plan Formulary |
CareMore Connect (HMO SNP)
|
$0.00 |
$320 |
to be determined |
4 |
Tier 4 |
25% | 25% | P | $1,439.00 |
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 |
CareMore ESRD (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$85.00 | $212.50 | P | $1,439.00 |
Browse Plan Formulary |
CareMore ESRD (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$85.00 | $212.50 | P | $1,439.00 |
Browse Plan Formulary |
CareMore Heart (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$85.00 | $212.50 | P | $1,439.00 |
Browse Plan Formulary |
CareMore Heart (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$85.00 | $212.50 | P | $1,439.00 |
Browse Plan Formulary |
CareMore Reliance (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$85.00 | $212.50 | P | $1,439.00 |
Browse Plan Formulary |
CareMore Reliance (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$85.00 | $212.50 | P | $1,439.00 |
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 |
CareMore Touch (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$50.00 | $125.00 | P | $1,439.00 |
Browse Plan Formulary |
CareMore Touch (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$50.00 | $125.00 | P | $1,439.00 |
Browse Plan Formulary |
CareMore Value Plus (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$85.00 | $212.50 | P | $1,439.58 |
Browse Plan Formulary |
CareMore Value Plus (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$85.00 | $212.50 | P | $1,439.58 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$50.00 | $100.00 | P | $1,444.75 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$50.00 | $100.00 | P | $1,444.75 |
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 |
Citizens Choice Healthplan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,490.01 |
Browse Plan Formulary |
Citizens Choice Healthplan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,490.01 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$90.00 | $180.00 | P | $1,460.51 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$90.00 | $180.00 | P | $1,460.51 |
Browse Plan Formulary |
Health Net Healthy Heart Plan 1 (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,472.92 |
Browse Plan Formulary |
Health Net Healthy Heart Plan 1 (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,472.92 |
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 |
Health Net Seniority Plus Ruby Plan 1 (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,472.92 |
Browse Plan Formulary |
Health Net Seniority Plus Ruby Plan 1 (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,472.92 |
Browse Plan Formulary |
Humana Gold Plus H0108-011 (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $230.00 | P | $1,420.33 |
Browse Plan Formulary |
Inter Valley Health Plan Service To Seniors (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$67.00 | $134.00 | P | $1,444.75 |
Browse Plan Formulary |
Inter Valley Health Plan Total Fit (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $210.00 | P | $1,444.75 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$45.00 | n/a | P | $1,464.58 |
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 |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$45.00 | n/a | P | $1,464.58 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | n/a | P | $1,464.58 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | n/a | P | $1,464.58 |
Browse Plan Formulary |
Salud con Health Net Medicare Advantage (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,472.92 |
Browse Plan Formulary |
Salud con Health Net Medicare Advantage (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,472.92 |
Browse Plan Formulary |
StartSmart with CareMore (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$95.00 | $237.50 | P | $1,439.00 |
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 |
StartSmart with CareMore (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$95.00 | $237.50 | P | $1,439.00 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$8.80 |
$0 |
to be determined |
3 |
Tier 3 |
$43.00 | n/a | P | $1,464.58 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$8.80 |
$0 |
to be determined |
3 |
Tier 3 |
$43.00 | n/a | P | $1,464.58 |
Browse Plan Formulary |
Health Net Healthy Heart Plan 2 (HMO)
|
$20.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,472.92 |
Browse Plan Formulary |
Health Net Healthy Heart Plan 2 (HMO)
|
$20.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,472.92 |
Browse Plan Formulary |
Care1st TotalDual Plan (HMO SNP)
|
$30.80 |
$320 |
to be determined |
3 |
Tier 3 |
25% | 25% | P | $1,439.31 |
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 |
Care1st TotalDual Plan (HMO SNP)
|
$30.80 |
$320 |
to be determined |
3 |
Tier 3 |
25% | 25% | P | $1,439.31 |
Browse Plan Formulary |
Easy Choice Freedom Plan (HMO SNP)
|
$30.80 |
$320 |
to be determined |
4 |
Tier 4 |
25% | 25% | P | $1,460.51 |
Browse Plan Formulary |
Easy Choice Freedom Plan (HMO SNP)
|
$30.80 |
$320 |
to be determined |
4 |
Tier 4 |
25% | 25% | P | $1,460.51 |
Browse Plan Formulary |
L.A. Care Health Plan Medicare Advantage (HMO SNP)
|
$30.80 |
$320 |
to be determined |
2 |
Tier 2 |
n/a | n/a | P | $1,445.77 |
Browse Plan Formulary |
L.A. Care Health Plan Medicare Advantage (HMO SNP)
|
$30.80 |
$320 |
to be determined |
2 |
Tier 2 |
n/a | n/a | P | $1,445.77 |
Browse Plan Formulary |
Brand New Day (HMO SNP)
|
$30.90 |
$320 |
to be determined |
2 |
Tier 2 |
25% | 25% | P | $1,460.97 |
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 |
Brand New Day (HMO SNP)
|
$30.90 |
$320 |
to be determined |
2 |
Tier 2 |
25% | 25% | P | $1,460.97 |
Browse Plan Formulary |
Brand New Day HMO Extra Care (HMO)
|
$30.90 |
$320 |
to be determined |
2 |
Tier 2 |
25% | 25% | P | $1,460.97 |
Browse Plan Formulary |
Brand New Day HMO Extra Care (HMO)
|
$30.90 |
$320 |
to be determined |
2 |
Tier 2 |
25% | 25% | P | $1,460.97 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO SNP)
|
$30.90 |
$320 |
to be determined |
4 |
Tier 4 |
25% | 25% | P | $1,444.75 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO SNP)
|
$30.90 |
$320 |
to be determined |
4 |
Tier 4 |
25% | 25% | P | $1,444.75 |
Browse Plan Formulary |
Humana Gold Plus H0108-012 (HMO-POS)
|
$39.00 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $230.00 | P | $1,420.33 |
Browse Plan Formulary |