Lupron Depot 1 KIT in 1 CARTON (1 KIT in 1 CARTON ) (NDC: 00074347303)
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 Choice Plan 2 (Regional PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | None | $5,921.43 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
|
$0.00 |
$0 |
Some Generics |
5 |
Specialty Tier |
33% | 33% | None | $6,028.18 |
Browse Plan Formulary |
AARP MedicareComplete Plus (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | None | $6,028.18 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P | $6,254.32 |
Browse Plan Formulary |
AvMed Medicare Choice (HMO)
|
$0.00 |
$0 |
Many Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | None | $6,115.94 |
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 |
BlueMedicare HMO (HMO)
|
$0.00 |
$0 |
All Generics |
5 |
Specialty Tier |
33% | 33% | None | $5,995.52 |
Browse Plan Formulary |
BlueMedicare Regional PPO (Regional PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | None | $6,378.14 |
Browse Plan Formulary |
CareFree PLUS (HMO)
|
$0.00 |
$0 |
Few Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | P Q:1 /168Days | $5,992.58 |
Browse Plan Formulary |
CareHeart (HMO SNP)
|
$0.00 |
$0 |
Many Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | P Q:1 /168Days | $5,992.58 |
Browse Plan Formulary |
CareOne PLUS (HMO)
|
$0.00 |
$0 |
Many Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | P Q:1 /168Days | $5,992.58 |
Browse Plan Formulary |
Clear Skies (HMO SNP)
|
$0.00 |
$0 |
All Generics |
4 |
Specialty Tier |
33% | 33% | P | $6,075.03 |
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 Ideal (HMO-POS)
|
$0.00 |
$0 |
Many Generics |
4 |
Specialty Tier |
33% | n/a | P | $6,059.79 |
Browse Plan Formulary |
Coventry Summit Plus (HMO)
|
$0.00 |
$0 |
Many Generics |
4 |
Specialty Tier |
33% | n/a | P | $6,059.79 |
Browse Plan Formulary |
Coventry Vista Ideal (HMO)
|
$0.00 |
$0 |
Many Generics |
4 |
Specialty Tier |
33% | n/a | P | $6,059.79 |
Browse Plan Formulary |
Day Break (HMO)
|
$0.00 |
$0 |
All Generics |
4 |
Specialty Tier |
33% | 33% | P | $6,075.03 |
Browse Plan Formulary |
Healthy Advantage Plan (HMO)
|
$0.00 |
$0 |
Many Generics |
3 |
Preferred Brand |
25% | n/a | None | $5,835.75 |
Browse Plan Formulary |
Humana Gold Plus H1036-054C (HMO)
|
$0.00 |
$0 |
Many Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | P Q:1 /168Days | $5,992.58 |
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 |
Humana Gold Plus H1036-164 (HMO)
|
$0.00 |
$0 |
Few Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | P Q:1 /168Days | $5,992.58 |
Browse Plan Formulary |
Humana Gold Plus SNP-CVD/CHF H1036-189 (HMO SNP)
|
$0.00 |
$0 |
Many Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | P Q:1 /168Days | $5,992.58 |
Browse Plan Formulary |
Humana Gold Plus SNP-DB H1036-188 (HMO SNP)
|
$0.00 |
$0 |
Many Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | P Q:1 /168Days | $5,992.58 |
Browse Plan Formulary |
Humana Reader''s Digest Healthy Living Plan (Regional PPO)
|
$0.00 |
$0 |
Few Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | P Q:1 /168Days | $5,992.58 |
Browse Plan Formulary |
Leon Medical Centers Health Plans - Leon Cares (HMO)
|
$0.00 |
$0 |
All Generics |
3 |
Specialty Tier |
33% | n/a | P | $5,870.01 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax (HMO)
|
$0.00 |
$0 |
Many Generics |
4 |
Specialty Tier |
25% | n/a | P | $6,091.73 |
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 Chronic Care (HMO SNP)
|
$0.00 |
$0 |
Many Generics |
4 |
Specialty Tier |
25% | n/a | P | $6,091.73 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax Value RX (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | n/a | P | $6,091.73 |
Browse Plan Formulary |
Preferred Medical Plan Choice (HMO)
|
$0.00 |
$0 |
Many Generics, Some Brands |
5 |
Specialty Tier |
33% | n/a | Q:1 /168Days | $6,051.52 |
Browse Plan Formulary |
Preferred Medical Plan Value (HMO)
|
$0.00 |
$0 |
Many Generics |
5 |
Specialty Tier |
33% | n/a | Q:1 /168Days | $6,051.52 |
Browse Plan Formulary |
PUP REWARDS (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | n/a | Q:1 /168Days | $6,038.96 |
Browse Plan Formulary |
Simply Extra (HMO)
|
$0.00 |
$0 |
Many Generics |
5 |
Specialty Tier |
33% | n/a | P | $5,788.35 |
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 |
Simply Level (HMO SNP)
|
$0.00 |
$0 |
Many Generics |
5 |
Specialty Tier |
33% | n/a | P | $5,788.35 |
Browse Plan Formulary |
Simply More (HMO)
|
$0.00 |
$0 |
All Generics, All Brands |
5 |
Specialty Tier |
33% | n/a | P | $5,788.35 |
Browse Plan Formulary |
Simply Options (HMO-POS)
|
$0.00 |
$0 |
Many Generics |
5 |
Specialty Tier |
33% | n/a | P | $5,788.35 |
Browse Plan Formulary |
SunPlus Advantage Plan (HMO)
|
$0.00 |
$0 |
All Generics, All Brands |
3 |
Preferred Brand |
$0.00 | n/a | None | $5,835.75 |
Browse Plan Formulary |
SunPlus Diabetes Special Needs Plan (HMO SNP)
|
$0.00 |
$0 |
All Generics, All Brands |
3 |
Preferred Brand |
$0.00 | n/a | None | $5,835.75 |
Browse Plan Formulary |
Sunrise (HMO)
|
$0.00 |
$0 |
All Generics |
4 |
Specialty Tier |
33% | 33% | P | $6,075.03 |
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 Choice (HMO)
|
$0.00 |
$0 |
All Generics, All Brands |
4 |
Specialty Tier |
33% | n/a | P Q:1 /168Days | $6,156.25 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$0 |
All Generics |
4 |
Specialty Tier |
33% | n/a | P Q:1 /168Days | $6,156.25 |
Browse Plan Formulary |
PUP EXTRA (HMO SNP)
|
$4.90 |
$0 |
to be determined |
4 |
Tier 4 |
25% | n/a | Q:1 /168Days | $5,921.43 |
Browse Plan Formulary |
Sunny Days (HMO SNP)
|
$4.90 |
$325 |
to be determined |
4 |
Tier 4 |
15% | 15% | P | $6,075.03 |
Browse Plan Formulary |
WellCare Select (HMO-POS SNP)
|
$8.50 |
$325 |
to be determined |
4 |
Tier 4 |
25% | n/a | P Q:1 /168Days | $6,046.01 |
Browse Plan Formulary |
WellCare Liberty (HMO SNP)
|
$11.80 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | P Q:1 /168Days | $6,156.25 |
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 Access (HMO SNP)
|
$12.20 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | P Q:1 /168Days | $6,156.25 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-077A (HMO SNP)
|
$17.90 |
$325 |
to be determined |
5 |
Tier 5 |
25% | n/a | P Q:1 /168Days | $5,992.58 |
Browse Plan Formulary |
Coventry Summit Maximum (HMO SNP)
|
$18.20 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | P | $6,041.25 |
Browse Plan Formulary |
CareNeeds (HMO SNP)
|
$20.30 |
$325 |
to be determined |
5 |
Tier 5 |
25% | n/a | P Q:1 /168Days | $5,992.58 |
Browse Plan Formulary |
Humana Gold Plus SNP-I H1036-187 (HMO SNP)
|
$21.30 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:1 /168Days | $5,992.58 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-163 (HMO SNP)
|
$21.90 |
$325 |
to be determined |
5 |
Tier 5 |
25% | n/a | P Q:1 /168Days | $5,992.58 |
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 |
Medica HealthCare Plans MedicareMax Plus (HMO SNP)
|
$23.40 |
$325 |
to be determined |
4 |
Tier 4 |
25% | n/a | P | $6,091.73 |
Browse Plan Formulary |
Coventry Vista Maximum (HMO SNP)
|
$24.70 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | P | $6,041.25 |
Browse Plan Formulary |
MediMax (HMO)
|
$24.70 |
$325* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
25% | n/a | None | $5,835.75 |
Browse Plan Formulary |
CareNeeds PLUS (HMO SNP)
|
$24.80 |
$325 |
to be determined |
5 |
Tier 5 |
25% | n/a | P Q:1 /168Days | $5,992.58 |
Browse Plan Formulary |
Simply Care (HMO SNP)
|
$24.80 |
$0 |
Many Generics |
5 |
Specialty Tier |
33% | n/a | P | $5,790.14 |
Browse Plan Formulary |
Simply Complete (HMO SNP)
|
$24.80 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P | $5,788.35 |
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 RP (Regional PPO SNP)
|
$24.80 |
$325 |
to be determined |
5 |
Tier 5 |
15% | 15% | None | $5,921.43 |
Browse Plan Formulary |
Coventry Vista Maximum Choice (HMO SNP)
|
$25.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | P | $6,041.25 |
Browse Plan Formulary |
Simply Comfort (HMO SNP)
|
$25.80 |
$0 |
Many Generics |
5 |
Specialty Tier |
33% | n/a | P | $5,790.14 |
Browse Plan Formulary |
HumanaChoice R5826-005 (Regional PPO)
|
$28.10 |
$0 |
Few Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | P Q:1 /168Days | $5,992.58 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$33.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P | $6,234.59 |
Browse Plan Formulary |
HumanaChoice H5415-056 (PPO)
|
$42.00 |
$0 |
Few Generics, Few Brands |
4 |
Specialty Tier |
33% | n/a | P Q:1 /168Days | $5,992.58 |
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 |
Humana Gold Choice H8145-061 (PFFS)
|
$102.00 |
$0 |
Few Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | P Q:1 /168Days | $5,992.58 |
Browse Plan Formulary |