Lupron Depot-PED 1 KIT in 1 CARTON (1 KIT in 1 CARTON ) (NDC: 00074377903)
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 (HMO)
![Email Prescription and/or Health Benefit details for AARP MedicareComplete SecureHorizons (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $5,524.19 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 1 (HMO)
![Email Prescription and/or Health Benefit details for AARP MedicareComplete SecureHorizons Plan 1 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Some Generics |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $5,524.19 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
![Email Prescription and/or Health Benefit details for AARP MedicareComplete SecureHorizons Plan 2 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Some Generics |
4 |
Non-Preferred Brand |
$92.00 | $266.00 | None | $5,524.19 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Select Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Some Generics |
5 |
Specialty Tier |
33% | 33% | P | $5,731.50 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
![Email Prescription and/or Health Benefit details for Blue Shield 65 Plus (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Many Generics |
4 |
Injectable Drugs |
25% | 25% | P | $5,481.12 |
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 Shield 65 Plus Choice Plan (HMO)
![Email Prescription and/or Health Benefit details for Blue Shield 65 Plus Choice Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Many Generics |
4 |
Injectable Drugs |
25% | 25% | P | $5,481.12 |
Browse Plan Formulary |
Brand New Day (HMO)
![Email Prescription and/or Health Benefit details for Brand New Day (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Many Generics |
2 |
Brand |
$40.00 | $80.00 | S Q:1 /84Days | $5,420.96 |
Browse Plan Formulary |
Care1st AdvantageOptimum Plan (HMO)
![Email Prescription and/or Health Benefit details for Care1st AdvantageOptimum Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Many Generics |
5 |
Specialty Tier |
30% | 30% | P | $5,549.68 |
Browse Plan Formulary |
Care1st TotalAdvantage Plan (HMO)
![Email Prescription and/or Health Benefit details for Care1st TotalAdvantage Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Many Generics |
5 |
Specialty Tier |
30% | 30% | P | $5,548.58 |
Browse Plan Formulary |
CCHP Senior Plan B-only Plan (HMO)
![Email Prescription and/or Health Benefit details for CCHP Senior Plan B-only Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$325 |
to be determined |
3 |
Tier 3 |
20% | 20% | P | $5,449.65 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
![Email Prescription and/or Health Benefit details for Central Health Medicare Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
All Generics |
4 |
Non-Preferred Brand |
$50.00 | $100.00 | None | $5,567.19 |
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 |
Central Health Premier Plan (HMO)
![Email Prescription and/or Health Benefit details for Central Health Premier Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
25% | 25% | None | $5,567.19 |
Browse Plan Formulary |
Citizens Choice Healthplan (HMO)
![Email Prescription and/or Health Benefit details for Citizens Choice Healthplan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Many Generics |
2 |
Preferred Brand |
$15.00 | $30.00 | None | $5,365.82 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
![Email Prescription and/or Health Benefit details for Easy Choice Best Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Many Generics |
5 |
Specialty Tier |
25% | 25% | Q:1 /84Days | $5,420.81 |
Browse Plan Formulary |
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 |
Many Generics |
5 |
Specialty Tier |
25% | 25% | Q:1 /84Days | $5,420.96 |
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 |
Many Generics |
5 |
Specialty Tier |
25% | 25% | Q:1 /84Days | $5,420.96 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
![Email Prescription and/or Health Benefit details for Health Net Gold Select (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Many Generics |
5 |
Specialty Tier |
33% | 33% | None | $5,698.38 |
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 |
Health Net Healthy Heart Plan 1 (HMO)
![Email Prescription and/or Health Benefit details for Health Net Healthy Heart Plan 1 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Many Generics |
5 |
Specialty Tier |
33% | 33% | None | $5,698.38 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
![Email Prescription and/or Health Benefit details for Health Net Jade (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Many Generics |
5 |
Specialty Tier |
33% | 33% | None | $5,698.38 |
Browse Plan Formulary |
Health Net Seniority Plus Ruby Plan 1 (HMO)
![Email Prescription and/or Health Benefit details for Health Net Seniority Plus Ruby Plan 1 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Many Generics |
5 |
Specialty Tier |
33% | 33% | None | $5,698.38 |
Browse Plan Formulary |
Heart First (HMO SNP)
![Email Prescription and/or Health Benefit details for Heart First (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Many Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | None | $5,504.42 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
![Email Prescription and/or Health Benefit details for Kaiser Permanente Senior Advantage B Only South (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $130.00 | None | $5,690.76 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
![Email Prescription and/or Health Benefit details for Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
All Generics, Few Brands |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | None | $5,690.76 |
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 Balance (HMO SNP)
![Email Prescription and/or Health Benefit details for SCAN Balance (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Many Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | None | $5,504.42 |
Browse Plan Formulary |
SCAN Classic (HMO)
![Email Prescription and/or Health Benefit details for SCAN Classic (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Many Generics |
5 |
Specialty Tier |
33% | n/a | None | $5,504.42 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
![Email Prescription and/or Health Benefit details for SCAN Healthy at Home (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Many Generics |
5 |
Specialty Tier |
33% | n/a | None | $5,504.42 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
![Email Prescription and/or Health Benefit details for Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$11.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $5,690.76 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan North (HMO SNP)
![Email Prescription and/or Health Benefit details for Senior Advantage Medicare Medi-Cal Plan North (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$16.60 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $5,690.39 |
Browse Plan Formulary |
Health Net Healthy Heart Plan 2 (HMO)
![Email Prescription and/or Health Benefit details for Health Net Healthy Heart Plan 2 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$23.90 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | None | $5,698.38 |
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 |
UnitedHealthcare Dual Complete (HMO SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Dual Complete (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$26.90 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $5,524.19 |
Browse Plan Formulary |
SCAN Plus (HMO)
![Email Prescription and/or Health Benefit details for SCAN Plus (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$27.50 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $5,504.42 |
Browse Plan Formulary |
Care1st AdvantageOptimum Plan (HMO)
![Email Prescription and/or Health Benefit details for Care1st AdvantageOptimum Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$28.00 |
$0 |
Many Generics |
5 |
Specialty Tier |
30% | 30% | P | $5,548.58 |
Browse Plan Formulary |
CCHP Senior Select Program (HMO SNP)
![Email Prescription and/or Health Benefit details for CCHP Senior Select Program (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | P | $5,449.65 |
Browse Plan Formulary |
Brand New Day (HMO SNP)
![Email Prescription and/or Health Benefit details for Brand New Day (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.80 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | S Q:1 /84Days | $5,420.96 |
Browse Plan Formulary |
Brand New Day D SNP (HMO SNP)
![Email Prescription and/or Health Benefit details for Brand New Day D SNP (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.80 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | S Q:1 /84Days | $5,420.96 |
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 Extra Care (HMO)
![Email Prescription and/or Health Benefit details for Brand New Day HMO Extra Care (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.80 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | S Q:1 /84Days | $5,420.96 |
Browse Plan Formulary |
Care1st TotalDual Plan (HMO SNP)
![Email Prescription and/or Health Benefit details for Care1st TotalDual Plan (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.80 |
$325 |
Few Generics |
5 |
Specialty Tier |
25% | 25% | P | $5,548.58 |
Browse Plan Formulary |
Care1st TotalDual Plan (HMO SNP)
![Email Prescription and/or Health Benefit details for Care1st TotalDual Plan (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.80 |
$325 |
Few Generics |
5 |
Specialty Tier |
25% | 25% | P | $5,548.58 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
![Email Prescription and/or Health Benefit details for Health Net Seniority Plus Amber I (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.80 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | None | $5,698.38 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
![Email Prescription and/or Health Benefit details for Health Net Seniority Plus Amber II (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.80 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | None | $5,698.38 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
![Email Prescription and/or Health Benefit details for Health Net Seniority Plus Amber II (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.80 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | None | $5,698.38 |
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 |
Molina Medicare Options Plus (HMO SNP)
![Email Prescription and/or Health Benefit details for Molina Medicare Options Plus (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.80 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
25% | n/a | P Q:1 /84Days | $5,626.08 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO SNP)
![Email Prescription and/or Health Benefit details for Central Health Medi-Medi Plan (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.90 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
25% | 25% | None | $5,567.19 |
Browse Plan Formulary |
Freedom Plan (HMO SNP)
![Email Prescription and/or Health Benefit details for Freedom Plan (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.90 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | Q:1 /84Days | $5,420.81 |
Browse Plan Formulary |
L.A. Care Health Plan Medicare Advantage (HMO SNP)
![Email Prescription and/or Health Benefit details for L.A. Care Health Plan Medicare Advantage (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.90 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
n/a | n/a | S Q:1 /84Days | $5,419.68 |
Browse Plan Formulary |
SCAN Connections (HMO SNP)
![Email Prescription and/or Health Benefit details for SCAN Connections (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.90 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
n/a | n/a | None | $5,504.42 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
![Email Prescription and/or Health Benefit details for SCAN Connections at Home (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.90 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
n/a | n/a | None | $5,504.42 |
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 |
Humana Gold Plus H0108-028 (HMO)
![Email Prescription and/or Health Benefit details for Humana Gold Plus H0108-028 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$32.00 |
$0 |
Few Generics, Few Brands |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P Q:1 /90Days | $5,491.58 |
Browse Plan Formulary |
CCHP Senior Program (HMO)
![Email Prescription and/or Health Benefit details for CCHP Senior Program (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$45.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Specialty Tier |
20% | 20% | P | $5,449.65 |
Browse Plan Formulary |
SCAN Classic (HMO)
![Email Prescription and/or Health Benefit details for SCAN Classic (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $5,504.42 |
Browse Plan Formulary |
Humana Gold Plus H0108-027 (HMO)
![Email Prescription and/or Health Benefit details for Humana Gold Plus H0108-027 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$62.00 |
$0 |
Some Generics, Few Brands |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P Q:1 /90Days | $5,491.58 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage Alam., SF, Napa (HMO)
![Email Prescription and/or Health Benefit details for Kaiser Permanente Senior Advantage Alam., SF, Napa (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$76.00 |
$0 |
All Generics, Few Brands |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | None | $5,690.39 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
![Email Prescription and/or Health Benefit details for Health Net Healthy Heart (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$89.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | None | $5,698.38 |
Browse Plan Formulary |