LUPRON DEPOT-4 MONTH KIT (1.5 ML ) (NDC: 00074368303)
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 Choice Plan 2 (Regional PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | None | $3,608.60 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | None | $3,613.61 |
Browse Plan Formulary |
AARP MedicareComplete Plus (HMO-POS)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | None | $3,613.61 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | S | $3,604.14 |
Browse Plan Formulary |
AvMed Medicare Choice (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | None | $3,604.02 |
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 |
BlueMedicare Regional PPO (Regional PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $3,662.01 |
Browse Plan Formulary |
CareDirect (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$45.00 | $125.00 | P Q:1 /120Days | $3,558.94 |
Browse Plan Formulary |
CareFree (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$45.00 | $125.00 | P Q:1 /120Days | $3,558.94 |
Browse Plan Formulary |
CareOne (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$45.00 | $125.00 | P Q:1 /120Days | $3,558.94 |
Browse Plan Formulary |
Coventry Summit Ideal (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | P | $3,604.05 |
Browse Plan Formulary |
Coventry Summit Plus (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | P | $3,604.05 |
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 |
Coventry Summit Select (HMO-POS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | P | $3,604.05 |
Browse Plan Formulary |
Coventry Vista Ideal (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | P | $3,604.05 |
Browse Plan Formulary |
Coventry Vista Prime (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | P | $3,604.05 |
Browse Plan Formulary |
Humana Gold Plus H1036-065C (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$45.00 | $125.00 | P Q:1 /120Days | $3,558.94 |
Browse Plan Formulary |
Humana Gold Plus SNP-DB H1036-121C (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$45.00 | $125.00 | P Q:1 /120Days | $3,558.94 |
Browse Plan Formulary |
Humana Reader's Digest Healthy Living Plan (Regional PPO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$81.00 | $233.00 | P Q:1 /120Days | $3,605.82 |
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 |
Medica HealthCare Plans MedicareMax (PSO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | P | n/a |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax Chronic Care (PSO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | P | n/a |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax Value RX (PSO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | P | n/a |
Browse Plan Formulary |
Medicare Masterpiece (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | S | $3,604.14 |
Browse Plan Formulary |
Medicare Masterpiece (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | S | $3,604.14 |
Browse Plan Formulary |
Medicare Masterpiece Premier - COPD (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | S | $3,604.14 |
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 - Dementia (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | S | $3,604.14 |
Browse Plan Formulary |
Medicare Masterpiece Premier - Diabetes, CHF, CVD (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | S | $3,604.14 |
Browse Plan Formulary |
Molina Medicare Options (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $3,576.42 |
Browse Plan Formulary |
Preferred Choice Broward (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $3,604.28 |
Browse Plan Formulary |
Preferred Gold Option (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $3,604.28 |
Browse Plan Formulary |
Preferred Medicare Assist (HMO-POS SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
25% | 25% | P | $3,604.28 |
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 |
Preferred Select Care (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $3,604.28 |
Browse Plan Formulary |
PUP EASY (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | Q:1 /112Days | $3,613.61 |
Browse Plan Formulary |
PUP REWARDS (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | Q:1 /112Days | $3,611.20 |
Browse Plan Formulary |
SunPlus Advantage Plan (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$0.00 | n/a | None | $3,714.79 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$0.00 |
$320 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $3,607.09 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | P | $3,678.98 |
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 Value (HMO-POS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | P | $3,702.89 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$1.10 |
$320 |
to be determined |
4 |
Tier 4 |
25% | 25% | P | $3,576.42 |
Browse Plan Formulary |
Coventry Vista Maximum Choice (HMO SNP)
|
$6.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | P | $3,604.05 |
Browse Plan Formulary |
WellCare Select (HMO-POS SNP)
|
$18.10 |
$320 |
to be determined |
4 |
Tier 4 |
25% | n/a | P | $3,661.35 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$19.20 |
$320 |
to be determined |
4 |
Tier 4 |
25% | n/a | P | $3,678.17 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax Plus (PSO SNP)
|
$19.40 |
$320 |
to be determined |
4 |
Tier 4 |
25% | n/a | 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 |
Coventry Summit Maximum (HMO SNP)
|
$21.40 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | P | $3,604.05 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-162 (HMO SNP)
|
$21.60 |
$320 |
to be determined |
4 |
Tier 4 |
$93.00 | $269.00 | P Q:1 /120Days | $3,558.94 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-103A (HMO SNP)
|
$22.90 |
$320 |
to be determined |
4 |
Tier 4 |
$95.00 | $275.00 | P Q:1 /120Days | $3,558.94 |
Browse Plan Formulary |
Amerivantage Specialty + Rx (HMO SNP)
|
$23.80 |
$320 |
to be determined |
5 |
Tier 5 |
25% | 25% | P | $3,573.21 |
Browse Plan Formulary |
CareNeeds (HMO SNP)
|
$23.80 |
$320 |
to be determined |
4 |
Tier 4 |
$95.00 | $275.00 | P Q:1 /120Days | $3,558.94 |
Browse Plan Formulary |
CareNeeds PLUS (HMO SNP)
|
$23.80 |
$320 |
to be determined |
4 |
Tier 4 |
$95.00 | $275.00 | P Q:1 /120Days | $3,558.94 |
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 |
Coventry Vista Maximum (HMO SNP)
|
$23.80 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | P | $3,604.05 |
Browse Plan Formulary |
MediMax (HMO)
|
$23.80 |
$0 |
to be determined |
3 |
Tier 3 |
33% | n/a | None | $3,689.98 |
Browse Plan Formulary |
Medicare Masterpiece Plus (HMO-POS)
|
$29.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | S | $3,604.14 |
Browse Plan Formulary |
HumanaChoice R5826-005 (Regional PPO)
|
$34.80 |
$0 |
to be determined |
4 |
Tier 4 |
$85.00 | $245.00 | P Q:1 /120Days | $3,605.82 |
Browse Plan Formulary |
HumanaChoice H5415-056 (PPO)
|
$39.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P Q:1 /120Days | $3,572.13 |
Browse Plan Formulary |
Humana Gold Choice H8145-061 (PFFS)
|
$99.00 |
$0 |
to be determined |
3 |
Tier 3 |
$81.00 | $233.00 | P Q:1 /120Days | $3,588.24 |
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 H5415-068 (PPO)
|
$149.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P Q:1 /120Days | $3,558.94 |
Browse Plan Formulary |
BlueMedicare PPO (PPO)
|
$150.00 |
$105 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $3,569.02 |
Browse Plan Formulary |