DEGARELIX 240 MG INJ (2X120MG ) (NDC: 55566840101)
2014 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 |
Fidelis Secure Respect (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | 33% | None | $1,412.78 |
Browse Plan Formulary |
HealthPlus MedicarePlus AdvantageHMO-POS Option 0 (HMO-POS)
|
$0.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $1,422.02 |
Browse Plan Formulary |
Meridian Prime (HMO)
|
$0.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | P | $1,386.31 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$17.50 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $1,374.46 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$17.50 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $1,374.46 |
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 Plus Blue PPO Essential (PPO)
|
$17.50 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $1,374.46 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$17.50 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $1,374.46 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$17.50 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $1,374.46 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$27.40 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
n/a | n/a | P | $1,418.90 |
Browse Plan Formulary |
HumanaChoice R5826-006 P (Regional PPO)
|
$30.60 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $1,402.35 |
Browse Plan Formulary |
Fidelis Secure Comfort (HMO SNP)
|
$32.50 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | None | $1,412.78 |
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 |
Fidelis Secure Freedom (HMO SNP)
|
$32.50 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | None | $1,412.78 |
Browse Plan Formulary |
Fidelis Secure Liberty (HMO SNP)
|
$32.50 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $1,412.78 |
Browse Plan Formulary |
HealthPlus MedicarePlus Advantage D-SNP (HMO SNP)
|
$32.50 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
n/a | n/a | None | $1,422.02 |
Browse Plan Formulary |
Meridian Advantage Plan of Michigan (HMO SNP)
|
$32.50 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
n/a | n/a | P | $1,386.31 |
Browse Plan Formulary |
Midwest Advantage (HMO SNP)
|
$32.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Brand |
$0.00 | n/a | Q:6 /28Days | $1,387.72 |
Browse Plan Formulary |
Total Medicare Plus (HMO SNP)
|
$32.50 |
$310 |
Many Generics |
5 |
Specialty Tier |
25% | n/a | P Q:2 /365Days | $1,421.43 |
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 |
HealthPlus MedicarePlus AdvantagePPO Basic (PPO)
|
$48.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $1,422.02 |
Browse Plan Formulary |
Fidelis Secure Premier (HMO)
|
$52.00 |
$0 |
Many Generics |
4 |
Specialty Tier |
33% | 33% | None | $1,412.78 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$58.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
33% | 33% | None | $1,262.02 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$60.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | n/a | None | $1,393.20 |
Browse Plan Formulary |
HAP Senior Plus - Henry Ford (HMO)
|
$73.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
27% | 27% | None | $1,262.02 |
Browse Plan Formulary |
HealthPlus MedicarePlus AdvantageHMO-POS Option 1 (HMO-POS)
|
$98.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $1,422.02 |
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 |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$99.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
30% | 30% | None | $1,262.02 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$99.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $1,374.46 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$99.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $1,374.46 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$99.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $1,374.46 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$99.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $1,374.46 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$99.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $1,374.46 |
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 |
PriorityMedicare Merit (PPO)
|
$99.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | n/a | None | $1,393.20 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$99.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | n/a | None | $1,393.20 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$99.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | n/a | None | $1,393.20 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$99.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | n/a | None | $1,393.20 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$99.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | n/a | None | $1,393.20 |
Browse Plan Formulary |
Alliance Medicare PPO (PPO)
|
$124.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
33% | 33% | None | $1,262.02 |
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 |
PriorityMedicare (HMO-POS)
|
$138.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | n/a | None | $1,393.20 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$148.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $1,374.46 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$148.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $1,374.46 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$148.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $1,374.46 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$148.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $1,374.46 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$148.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $1,374.46 |
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 |
HealthPlus MedicarePlus AdvantageHMO-POS Option 2 (HMO-POS)
|
$150.00 |
$0 |
Many Generics |
3 |
Non-Preferred Brand |
$90.00 | $225.00 | None | $1,422.02 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$165.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | n/a | None | $1,393.20 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$165.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | n/a | None | $1,393.20 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$165.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | n/a | None | $1,393.20 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$165.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | n/a | None | $1,393.20 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$165.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | n/a | None | $1,393.20 |
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 |
HealthPlus MedicarePlus AdvantagePPO Enhanced (PPO)
|
$176.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $1,422.02 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$179.00 |
$50 |
All Generics |
4 |
Non-Preferred Brand |
31% | 31% | None | $1,262.02 |
Browse Plan Formulary |
Alliance Medicare PPO (PPO)
|
$203.00 |
$150 |
All Generics |
4 |
Non-Preferred Brand |
29% | 29% | None | $1,262.02 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$272.00 |
$0 |
Some Generics |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $1,374.46 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$272.00 |
$0 |
Some Generics |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $1,374.46 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$272.00 |
$0 |
Some Generics |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $1,374.46 |
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 Plus Blue PPO Assure (PPO)
|
$272.00 |
$0 |
Some Generics |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $1,374.46 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$272.00 |
$0 |
Some Generics |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $1,374.46 |
Browse Plan Formulary |