DEPO-PROVERA 400MG/ML VIAL (2.5 ML VIAL) (NDC: 00009062601)
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 |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$310 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $301.64 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$310 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $302.40 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$310 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $295.56 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$310 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $302.40 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$310 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $302.40 |
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 0 (HMO-POS)
|
$0.00 |
$310 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:10 /28Days | $291.30 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$17.50 |
$310 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $301.64 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$17.50 |
$310 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $302.40 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$17.50 |
$310 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $295.56 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$17.50 |
$310 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $302.40 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$17.50 |
$310 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $303.10 |
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 |
HumanaChoice R5826-006 P (Regional PPO)
|
$30.60 |
$310 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $288.12 |
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 | Q:10 /28Days | $288.87 |
Browse Plan Formulary |
McLarenAdvantage (HMO SNP)
|
$32.50 |
$310 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$95.00 | $285.00 | P | $290.65 |
Browse Plan Formulary |
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 | Q:10 /28Days | $291.30 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$94.00 |
$310 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $301.64 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$94.00 |
$310 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $302.40 |
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 Vitality (PPO)
|
$94.00 |
$310 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $295.56 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$94.00 |
$310 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $302.40 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$94.00 |
$310 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $303.10 |
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 | Q:10 /28Days | $291.30 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 | Some Generics | 3 |
Preferred Brand |
$40.00 | $100.00 | None | $302.40 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 | Some Generics | 3 |
Preferred Brand |
$40.00 | $100.00 | None | $302.40 |
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 |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 | Some Generics | 3 |
Preferred Brand |
$40.00 | $100.00 | None | $302.40 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 | Some Generics | 3 |
Preferred Brand |
$40.00 | $100.00 | None | $295.56 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 | Some Generics | 3 |
Preferred Brand |
$40.00 | $100.00 | None | $301.64 |
Browse Plan Formulary |
McLarenAdvantage (HMO)
|
$128.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$70.00 | $140.00 | P | $290.65 |
Browse Plan Formulary |
HealthPlus MedicarePlus AdvantageHMO-POS Option 2 (HMO-POS)
|
$150.00 |
$0 | Many Generics | 3 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:10 /28Days | $291.30 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$155.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $302.40 |
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 Signature (PPO)
|
$155.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $301.64 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$155.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $295.56 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$155.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $302.40 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$155.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $303.10 |
Browse Plan Formulary |
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 | Q:10 /28Days | $291.30 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$241.00 |
$0 | Some Generics | 3 |
Preferred Brand |
$35.00 | $87.50 | None | $302.40 |
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 |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$241.00 |
$0 | Some Generics | 3 |
Preferred Brand |
$35.00 | $87.50 | None | $302.40 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$241.00 |
$0 | Some Generics | 3 |
Preferred Brand |
$35.00 | $87.50 | None | $302.40 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$241.00 |
$0 | Some Generics | 3 |
Preferred Brand |
$35.00 | $87.50 | None | $295.56 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$241.00 |
$0 | Some Generics | 3 |
Preferred Brand |
$35.00 | $87.50 | None | $301.64 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$268.00 |
$0 | Some Generics | 3 |
Preferred Brand |
$40.00 | $100.00 | None | $303.10 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$268.00 |
$0 | Some Generics | 3 |
Preferred Brand |
$40.00 | $100.00 | None | $302.40 |
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)
|
$268.00 |
$0 | Some Generics | 3 |
Preferred Brand |
$40.00 | $100.00 | None | $295.56 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$268.00 |
$0 | Some Generics | 3 |
Preferred Brand |
$40.00 | $100.00 | None | $302.40 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$268.00 |
$0 | Some Generics | 3 |
Preferred Brand |
$40.00 | $100.00 | None | $301.64 |
Browse Plan Formulary |