DEPO-PROVERA 400MG/ML VIAL (2.5 ML VIAL) (NDC: 00009062601)
2013 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 Plan 1 (HMO)
|
$0.00 |
$0 | Some Generics | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $246.87 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 | Some Generics | 4 |
Non-Preferred Brand |
$92.00 | $266.00 | None | $246.87 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 | Some Generics | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $258.02 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Injectable Drugs |
25% | 25% | P | $246.01 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Injectable Drugs |
25% | 25% | P | $246.01 |
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)
|
$0.00 |
$0 | Many Generics | 2 |
Brand |
$40.00 | $80.00 | Q:10 /28Days | $258.50 |
Browse Plan Formulary |
Care1st AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 | Many Generics | 3 |
Preferred Brand |
$30.00 | $60.00 | P | $252.40 |
Browse Plan Formulary |
Care1st TotalAdvantage Plan (HMO)
|
$0.00 |
$0 | Many Generics | 3 |
Preferred Brand |
$30.00 | $60.00 | P | $252.40 |
Browse Plan Formulary |
CareMore Breathe (HMO SNP)
|
$0.00 |
$0 | All Generics, All Brands | 4 |
Non-Preferred Brand |
$85.00 | $212.50 | P | $275.61 |
Browse Plan Formulary |
CareMore Connect (HMO SNP)
|
$0.00 |
$325 | All Generics, Few Brands | 4 |
Non-Preferred Brand |
25% | 25% | P | $275.61 |
Browse Plan Formulary |
CareMore ESRD (HMO SNP)
|
$0.00 |
$0 | All Generics, All Brands | 4 |
Non-Preferred Brand |
$85.00 | $212.50 | P | $275.61 |
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 Heart (HMO SNP)
|
$0.00 |
$0 | All Generics, All Brands | 4 |
Non-Preferred Brand |
$85.00 | $212.50 | P | $275.61 |
Browse Plan Formulary |
CareMore Reliance (HMO SNP)
|
$0.00 |
$0 | All Generics, All Brands | 4 |
Non-Preferred Brand |
$85.00 | $212.50 | P | $275.61 |
Browse Plan Formulary |
CareMore Touch (HMO SNP)
|
$0.00 |
$0 | All Generics, All Brands | 4 |
Non-Preferred Brand |
$85.00 | $212.50 | P | $275.61 |
Browse Plan Formulary |
CareMore Value Plus (HMO)
|
$0.00 |
$0 | All Generics, All Brands | 4 |
Non-Preferred Brand |
$85.00 | $212.50 | P | $255.45 |
Browse Plan Formulary |
Citizens Choice Healthplan (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Injectable Drugs |
25% | 25% | P | $263.02 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 | Many Generics | 3 |
Preferred Brand |
$40.00 | $80.00 | Q:10 /28Days | $258.50 |
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 |
Freedom VIP Care (HMO SNP)
|
$0.00 |
$0 | Many Generics | 3 |
Preferred Brand |
$40.00 | $80.00 | Q:10 /28Days | $258.50 |
Browse Plan Formulary |
Freedom VIP Care COPD (HMO SNP)
|
$0.00 |
$0 | Many Generics | 3 |
Preferred Brand |
$40.00 | $80.00 | Q:10 /28Days | $258.50 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $247.02 |
Browse Plan Formulary |
Health Net Healthy Heart Plan 1 (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $247.02 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $247.02 |
Browse Plan Formulary |
Health Net Seniority Plus Ruby Plan 1 (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $247.02 |
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 |
Heart First (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$70.00 | $140.00 | None | $261.32 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$0.00 |
$0 | to be determined | 3 |
Tier 3 |
$45.00 | $90.00 | None | $266.19 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage Basic Fresno (HMO)
|
$0.00 |
$0 | All Generics, Few Brands | 3 |
Preferred Brand |
$45.00 | $90.00 | None | $270.55 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 | All Generics, Few Brands | 3 |
Preferred Brand |
$40.00 | $80.00 | None | $266.19 |
Browse Plan Formulary |
Positive Healthcare Partners (HMO SNP)
|
$0.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
25% | n/a | P | $252.40 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$70.00 | $140.00 | None | $261.32 |
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 |
SCAN Classic (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$80.00 | $160.00 | None | $261.32 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$80.00 | $160.00 | None | $261.32 |
Browse Plan Formulary |
StartSmart with CareMore (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $237.50 | P | $275.61 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$11.40 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $90.00 | None | $266.19 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan North (HMO SNP)
|
$16.60 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $90.00 | None | $270.55 |
Browse Plan Formulary |
Health Net Healthy Heart Plan 2 (HMO)
|
$23.90 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $247.02 |
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 |
UnitedHealthcare Dual Complete (HMO SNP)
|
$26.90 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | None | $246.87 |
Browse Plan Formulary |
Brand New Day (HMO SNP)
|
$29.80 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | Q:10 /28Days | $258.50 |
Browse Plan Formulary |
Brand New Day D SNP (HMO SNP)
|
$29.80 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | Q:10 /28Days | $258.50 |
Browse Plan Formulary |
Brand New Day HMO Extra Care (HMO)
|
$29.80 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | Q:10 /28Days | $258.50 |
Browse Plan Formulary |
Care1st TotalDual Plan (HMO SNP)
|
$29.80 |
$325 | Few Generics | 3 |
Preferred Brand |
25% | 25% | P | $252.40 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$29.80 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | None | $247.02 |
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 |
Health Net Seniority Plus Amber II (HMO SNP)
|
$29.80 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | None | $247.02 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$29.80 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$45.00 | $135.00 | P | $245.88 |
Browse Plan Formulary |
Freedom Plan (HMO SNP)
|
$29.90 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | 25% | Q:10 /28Days | $254.00 |
Browse Plan Formulary |
L.A. Care Health Plan Medicare Advantage (HMO SNP)
|
$29.90 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
n/a | n/a | Q:10 /28Days | $254.00 |
Browse Plan Formulary |
SCAN Connections (HMO SNP)
|
$29.90 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
n/a | n/a | None | $261.32 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
|
$29.90 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
n/a | n/a | None | $261.32 |
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 Enhanced Fresno (HMO)
|
$81.00 |
$0 | All Generics, Few Brands | 3 |
Preferred Brand |
$45.00 | $90.00 | None | $270.55 |
Browse Plan Formulary |