Vivelle Dot 0.025mg/d 3 PACKET in 1 CARTON / 8 POUCH in 1 PACKET / 1 PATCH in 1 POUCH / 3.5 d in 1 (3 PACKET in 1 CARTON / 8 ) (NDC: 00078036545)
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 | 3 |
Preferred Brand |
$45.00 | $125.00 | None | $225.98 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 | Some Generics | 3 |
Preferred Brand |
$45.00 | $125.00 | None | $225.81 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 | Some Generics | 3 |
Preferred Brand |
$45.00 | $125.00 | None | $225.98 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Premier (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $125.00 | None | $225.81 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 | Many Generics | 2 |
Preferred Brand |
$40.00 | $80.00 | Q:16 /30Days | $226.91 |
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 (HMO)
|
$0.00 |
$0 | Many Generics | 2 |
Preferred Brand |
$40.00 | $80.00 | Q:16 /30Days | $226.91 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 | Many Generics | 2 |
Preferred Brand |
$35.00 | $70.00 | Q:16 /30Days | $226.91 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 | Many Generics | 2 |
Preferred Brand |
$35.00 | $70.00 | Q:16 /30Days | $226.91 |
Browse Plan Formulary |
Brand New Day (HMO)
|
$0.00 |
$0 | Many Generics | 2 |
Brand |
$40.00 | $80.00 | P Q:8 /28Days | $231.90 |
Browse Plan Formulary |
Brand New Day (HMO)
|
$0.00 |
$0 | Many Generics | 2 |
Brand |
$40.00 | $80.00 | P Q:8 /28Days | $231.90 |
Browse Plan Formulary |
CareMore Breathe (HMO SNP)
|
$0.00 |
$0 | All Generics, All Brands | 4 |
Non-Preferred Brand |
$85.00 | $212.50 | Q:8 /28Days | $252.08 |
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 Breathe (HMO SNP)
|
$0.00 |
$0 | All Generics, All Brands | 4 |
Non-Preferred Brand |
$85.00 | $212.50 | Q:8 /28Days | $252.08 |
Browse Plan Formulary |
CareMore Connect (HMO SNP)
|
$0.00 |
$325 | All Generics, Few Brands | 4 |
Non-Preferred Brand |
25% | 25% | Q:8 /28Days | $252.09 |
Browse Plan Formulary |
CareMore ESRD (HMO SNP)
|
$0.00 |
$0 | All Generics, All Brands | 4 |
Non-Preferred Brand |
$85.00 | $212.50 | Q:8 /28Days | $252.08 |
Browse Plan Formulary |
CareMore ESRD (HMO SNP)
|
$0.00 |
$0 | All Generics, All Brands | 4 |
Non-Preferred Brand |
$85.00 | $212.50 | Q:8 /28Days | $252.08 |
Browse Plan Formulary |
CareMore Heart (HMO SNP)
|
$0.00 |
$0 | All Generics, All Brands | 4 |
Non-Preferred Brand |
$85.00 | $212.50 | Q:8 /28Days | $252.08 |
Browse Plan Formulary |
CareMore Heart (HMO SNP)
|
$0.00 |
$0 | All Generics, All Brands | 4 |
Non-Preferred Brand |
$85.00 | $212.50 | Q:8 /28Days | $252.08 |
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 Reliance (HMO SNP)
|
$0.00 |
$0 | All Generics, All Brands | 4 |
Non-Preferred Brand |
$85.00 | $212.50 | Q:8 /28Days | $252.08 |
Browse Plan Formulary |
CareMore Reliance (HMO SNP)
|
$0.00 |
$0 | All Generics, All Brands | 4 |
Non-Preferred Brand |
$85.00 | $212.50 | Q:8 /28Days | $252.08 |
Browse Plan Formulary |
CareMore Touch (HMO SNP)
|
$0.00 |
$0 | All Generics, All Brands | 4 |
Non-Preferred Brand |
$85.00 | $212.50 | Q:8 /28Days | $252.08 |
Browse Plan Formulary |
CareMore Touch (HMO SNP)
|
$0.00 |
$0 | All Generics, All Brands | 4 |
Non-Preferred Brand |
$85.00 | $212.50 | Q:8 /28Days | $252.08 |
Browse Plan Formulary |
CareMore Value Plus (HMO)
|
$0.00 |
$0 | All Generics, All Brands | 4 |
Non-Preferred Brand |
$85.00 | $212.50 | Q:8 /28Days | $233.67 |
Browse Plan Formulary |
CareMore Value Plus (HMO)
|
$0.00 |
$0 | All Generics, All Brands | 4 |
Non-Preferred Brand |
$85.00 | $212.50 | Q:8 /28Days | $233.67 |
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 Medicare Plan (HMO)
|
$0.00 |
$0 | All Generics | 4 |
Non-Preferred Brand |
$50.00 | $100.00 | Q:8 /28Days | $233.67 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 | All Generics | 4 |
Non-Preferred Brand |
$50.00 | $100.00 | Q:8 /28Days | $233.67 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$0.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
25% | 25% | Q:8 /28Days | $233.67 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$0.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
25% | 25% | Q:8 /28Days | $233.67 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 | Many Generics | 3 |
Preferred Brand |
$40.00 | $80.00 | P Q:8 /28Days | $231.78 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 | Many Generics | 3 |
Preferred Brand |
$40.00 | $80.00 | P Q:8 /28Days | $231.78 |
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 | P Q:8 /28Days | $231.82 |
Browse Plan Formulary |
Freedom VIP Care (HMO SNP)
|
$0.00 |
$0 | Many Generics | 3 |
Preferred Brand |
$40.00 | $80.00 | P Q:8 /28Days | $231.82 |
Browse Plan Formulary |
Freedom VIP Care COPD (HMO SNP)
|
$0.00 |
$0 | Many Generics | 3 |
Preferred Brand |
$40.00 | $80.00 | P Q:8 /28Days | $231.82 |
Browse Plan Formulary |
Freedom VIP Care COPD (HMO SNP)
|
$0.00 |
$0 | Many Generics | 3 |
Preferred Brand |
$40.00 | $80.00 | P Q:8 /28Days | $231.82 |
Browse Plan Formulary |
Golden State Medicare Health Plan, Golden (HMO) (HMO)
|
$0.00 |
$0 | Many Generics | 2 |
Preferred Brand |
$40.00 | $80.00 | None | $225.92 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $225.90 |
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 Gold Select (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $225.90 |
Browse Plan Formulary |
Health Net Healthy Heart Plan 1 (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $225.90 |
Browse Plan Formulary |
Health Net Healthy Heart Plan 1 (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $225.90 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $225.90 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $225.90 |
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 | $225.90 |
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 | Many Generics | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $225.90 |
Browse Plan Formulary |
Heart First (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 3 |
Preferred Brand |
$30.00 | $60.00 | None | $238.93 |
Browse Plan Formulary |
Heart First (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 3 |
Preferred Brand |
$30.00 | $60.00 | None | $238.93 |
Browse Plan Formulary |
Humana Gold Plus H0108-013 (HMO)
|
$0.00 |
$0 | Some Generics, Few Brands | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | P Q:8 /28Days | $228.31 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Tier 4 |
$65.00 | $130.00 | None | $252.70 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Tier 4 |
$65.00 | $130.00 | None | $252.70 |
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 LA, Orange Co. (HMO)
|
$0.00 |
$0 | All Generics, Few Brands | 4 |
Non-Preferred Brand |
$60.00 | $120.00 | None | $258.58 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 | All Generics, Few Brands | 4 |
Non-Preferred Brand |
$60.00 | $120.00 | None | $258.58 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 3 |
Preferred Brand |
$30.00 | $60.00 | None | $238.93 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 3 |
Preferred Brand |
$30.00 | $60.00 | None | $238.93 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 | Many Generics | 3 |
Preferred Brand |
$40.00 | $80.00 | None | $238.93 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 | Many Generics | 3 |
Preferred Brand |
$40.00 | $80.00 | None | $238.93 |
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 Healthy at Home (HMO SNP)
|
$0.00 |
$0 | Many Generics | 3 |
Preferred Brand |
$39.00 | $78.00 | None | $238.93 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 | Many Generics | 3 |
Preferred Brand |
$39.00 | $78.00 | None | $238.93 |
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 | Q:8 /28Days | $252.08 |
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 | Q:8 /28Days | $252.08 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$11.40 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $252.70 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$11.40 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $252.70 |
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 2 (HMO)
|
$23.90 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $225.90 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$26.90 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | None | $225.98 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H0108-016 (HMO SNP)
|
$27.40 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | P Q:8 /28Days | $228.31 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$27.50 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | 25% | None | $238.93 |
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% | P Q:8 /28Days | $231.90 |
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% | P Q:8 /28Days | $231.90 |
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 D SNP (HMO SNP)
|
$29.80 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | P Q:8 /28Days | $231.90 |
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% | P Q:8 /28Days | $231.90 |
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% | P Q:8 /28Days | $231.90 |
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% | P Q:8 /28Days | $231.90 |
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 | $225.90 |
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 | $225.90 |
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 | $225.90 |
Browse Plan Formulary |
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 | $225.90 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO SNP)
|
$29.90 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
25% | 25% | Q:8 /28Days | $233.67 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$29.90 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | 25% | P Q:8 /28Days | $231.67 |
Browse Plan Formulary |
Freedom Plan (HMO SNP)
|
$29.90 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | 25% | P Q:8 /28Days | $231.86 |
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 | P Q:8 /28Days | $231.86 |
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 |
OneCare (HMO SNP)
|
$29.90 |
$0 | Few Generics | 3 |
Non-Preferred Brand |
$0.00 | n/a | None | $231.03 |
Browse Plan Formulary |
SCAN Connections (HMO SNP)
|
$29.90 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
n/a | n/a | None | $238.93 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
|
$29.90 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
n/a | n/a | None | $238.93 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$29.90 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | None | $225.81 |
Browse Plan Formulary |
Health Net Healthy Heart Plan 2 (HMO)
|
$39.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $225.90 |
Browse Plan Formulary |
Humana Gold Plus H0108-014 (HMO-POS)
|
$39.00 |
$0 | Few Generics, Few Brands | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | P Q:8 /28Days | $228.31 |
Browse Plan Formulary |