OCTREOTIDE ACETATE INJECTION 1000MCG 1X5ML VIALMD (1X5 ML VIALMD) (NDC: 62756035240)
2015 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 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | 33% | P | $416.91 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
50% | 50% | P | $816.18 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $918.63 |
Browse Plan Formulary |
Amerivantage Specialty + Rx (HMO SNP)
|
$0.00 |
$320 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $918.63 |
Browse Plan Formulary |
AvMed Medicare Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $816.24 |
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 LifeTime (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
5 |
Specialty Tier |
33% | 33% | P | $264.91 |
Browse Plan Formulary |
BlueMedicare HMO MyTime (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
5 |
Specialty Tier |
33% | 33% | P | $277.80 |
Browse Plan Formulary |
CareDirect (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $228.14 |
Browse Plan Formulary |
CareHeart (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $228.14 |
Browse Plan Formulary |
CareOne (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $228.14 |
Browse Plan Formulary |
Coventry Summit Ideal (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Brand |
50% | 50% | P | $816.23 |
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 Vista Ideal (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
50% | 50% | P | $816.16 |
Browse Plan Formulary |
Freedom Medicare Plan Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Specialty Tier |
33% | 33% | P | $898.95 |
Browse Plan Formulary |
Freedom VIP Savings (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Specialty Tier |
33% | 33% | P | $898.09 |
Browse Plan Formulary |
Freedom VIP Savings COPD (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Specialty Tier |
33% | 33% | P | $898.09 |
Browse Plan Formulary |
HealthSun HealthAdvantage Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $260.64 |
Browse Plan Formulary |
Humana Gold Plus - Diabetes (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $228.14 |
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 - Heart (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $228.14 |
Browse Plan Formulary |
Humana Gold Plus H1036-065C (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $228.14 |
Browse Plan Formulary |
Humana Gold Plus H1036-237 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $228.14 |
Browse Plan Formulary |
Humana Gold Plus H1036-237 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $228.14 |
Browse Plan Formulary |
HumanaChoice R5826-074 (Regional PPO)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | P | $228.14 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Specialty Tier |
33% | 33% | P | $194.75 |
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 |
Optimum Gold Rewards Plan (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | 33% | P | $905.96 |
Browse Plan Formulary |
Optimum Platinum Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Specialty Tier |
33% | 33% | P | $905.96 |
Browse Plan Formulary |
Preferred Choice Broward (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Specialty Tier |
33% | 33% | P | $194.75 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $891.96 |
Browse Plan Formulary |
WellCare Essential (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $901.69 |
Browse Plan Formulary |
WellCare Value (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $903.73 |
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 |
Humana Gold Plus SNP-DE H1036-103A (HMO SNP)
|
$13.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $228.14 |
Browse Plan Formulary |
CareNeeds (HMO SNP)
|
$15.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $228.14 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$17.70 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $903.71 |
Browse Plan Formulary |
WellCare Liberty (HMO SNP)
|
$18.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $903.71 |
Browse Plan Formulary |
WellCare Select (HMO SNP)
|
$19.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $902.10 |
Browse Plan Formulary |
BlueMedicare Regional PPO (Regional PPO)
|
$20.20 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | P | $269.79 |
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-POS SNP)
|
$24.30 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Specialty Tier |
25% | 25% | P | $233.85 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$24.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $428.30 |
Browse Plan Formulary |
Preferred Medicare Assist (HMO-POS SNP)
|
$24.40 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Specialty Tier |
25% | 25% | P | $233.85 |
Browse Plan Formulary |
Coventry Summit Maximum (HMO SNP)
|
$24.60 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Brand |
50% | 50% | P | $614.85 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$24.80 |
$320 |
Yes, but No Gap Coverage for this drug. |
4 |
Specialty Tier |
25% | n/a | P | $816.24 |
Browse Plan Formulary |
Freedom Medi-Medi Full (HMO SNP)
|
$25.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P | $903.55 |
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 Medi-Medi Partial (HMO SNP)
|
$25.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P | $903.55 |
Browse Plan Formulary |
HealthSun MediMax (HMO)
|
$25.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $260.64 |
Browse Plan Formulary |
Optimum Emerald Full (HMO SNP)
|
$25.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
25% | 25% | P | $903.72 |
Browse Plan Formulary |
Optimum Emerald Partial (HMO SNP)
|
$25.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
25% | 25% | P | $903.72 |
Browse Plan Formulary |
Sunshine Health Advantage (HMO SNP)
|
$25.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Injectable Drugs |
$95.00 | $95.00 | None | $573.31 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP (Regional PPO SNP)
|
$25.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | P | $416.91 |
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 |
Aetna Medicare Premier Plan (PPO)
|
$35.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
50% | 50% | P | $816.18 |
Browse Plan Formulary |
HumanaChoice R5826-005 (Regional PPO)
|
$39.40 |
$100 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
30% | n/a | P | $228.14 |
Browse Plan Formulary |
HumanaChoice H5415-056 (PPO)
|
$43.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $228.14 |
Browse Plan Formulary |
Humana Gold Choice H8145-061 (PFFS)
|
$101.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $228.14 |
Browse Plan Formulary |
BlueMedicare PPO (PPO)
|
$127.10 |
$0 |
Yes, this drug has Gap Coverage. |
5 |
Specialty Tier |
33% | 33% | P | $269.57 |
Browse Plan Formulary |
Aetna Medicare Select Plus Plan (HMO)
|
$139.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
50% | 50% | P | $816.18 |
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 |
Aetna Medicare Select Plus Plan (PPO)
|
$139.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
50% | 50% | P | $816.18 |
Browse Plan Formulary |