Somatuline Depot 90mg/0.3mL 1 POUCH per CARTON / 1 SYRINGE in 1 POUCH / 0.3 mL in 1 SYRINGE (1 POUCH in 1 CARTON / 1 S ) (NDC: 15054009001)
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 |
Advantra Silver (HMO)
![Email Prescription and/or Health Benefit details for Advantra Silver (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $4,262.59 |
Browse Plan Formulary |
Advantra Silver (PPO)
![Email Prescription and/or Health Benefit details for Advantra Silver (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $4,262.59 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Classic Complete Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P | $4,187.51 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Classic Complete Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P | $4,187.51 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Classic Complete Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P | $4,300.68 |
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 |
Geisinger Gold Classic Complete Rx (HMO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Classic Complete Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P | $4,300.68 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Classic Complete Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P | $4,300.68 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Preferred Complete Rx (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P | $4,305.27 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Preferred Complete Rx (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P | $4,305.27 |
Browse Plan Formulary |
Humana Gold Plus H6859-001 (HMO)
![Email Prescription and/or Health Benefit details for Humana Gold Plus H6859-001 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | P Q:1 /28Days | $4,325.19 |
Browse Plan Formulary |
UPMC for Life HMO Deductible with Rx (HMO)
![Email Prescription and/or Health Benefit details for UPMC for Life HMO Deductible with Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,342.20 |
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 |
Cigna-HealthSpring TotalCare (HMO SNP)
![Email Prescription and/or Health Benefit details for Cigna-HealthSpring TotalCare (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$25.40 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P | $4,347.21 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Nursing Home Plan (PPO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$27.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $4,323.48 |
Browse Plan Formulary |
Cigna-HealthSpring Achieve (HMO SNP)
![Email Prescription and/or Health Benefit details for Cigna-HealthSpring Achieve (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$28.50 |
$280 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
26% | 26% | P | $4,333.31 |
Browse Plan Formulary |
AdvantraOne (PPO)
![Email Prescription and/or Health Benefit details for AdvantraOne (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $4,322.28 |
Browse Plan Formulary |
Cigna-HealthSpring Preferred (HMO)
![Email Prescription and/or Health Benefit details for Cigna-HealthSpring Preferred (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.50 |
$280 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
26% | 26% | P | $4,347.21 |
Browse Plan Formulary |
Cigna-HealthSpring Preferred (HMO)
![Email Prescription and/or Health Benefit details for Cigna-HealthSpring Preferred (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.50 |
$280 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
26% | 26% | P | $4,347.21 |
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 |
Advantra Cares (HMO SNP)
![Email Prescription and/or Health Benefit details for Advantra Cares (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$33.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | P | $4,262.52 |
Browse Plan Formulary |
AmeriHealth VIP Care (HMO SNP)
![Email Prescription and/or Health Benefit details for AmeriHealth VIP Care (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$33.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | P | $4,269.96 |
Browse Plan Formulary |
Geisinger Gold Secure Rx (HMO SNP)
![Email Prescription and/or Health Benefit details for Geisinger Gold Secure Rx (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$33.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P | $4,187.51 |
Browse Plan Formulary |
HumanaChoice H5525-006 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice H5525-006 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$34.00 |
$320 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P Q:1 /28Days | $4,325.19 |
Browse Plan Formulary |
UPMC for Life PPO High Deductible with Rx (PPO)
![Email Prescription and/or Health Benefit details for UPMC for Life PPO High Deductible with Rx (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,342.20 |
Browse Plan Formulary |
HumanaChoice R5826-002 (Regional PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice R5826-002 (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$39.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:1 /28Days | $4,246.85 |
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 |
Advantra Silver Plus (HMO)
![Email Prescription and/or Health Benefit details for Advantra Silver Plus (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $4,262.59 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (HMO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Standard Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $4,477.92 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (PPO)
![Email Prescription and/or Health Benefit details for UnitedHealthcare MedicareComplete Choice (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$49.00 |
$230* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | 33% | P | $4,323.48 |
Browse Plan Formulary |
Humana Gold Choice H8145-052 (PFFS)
![Email Prescription and/or Health Benefit details for Humana Gold Choice H8145-052 (PFFS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$62.00 |
$320 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P Q:1 /28Days | $4,283.59 |
Browse Plan Formulary |
Advantra Silver Plus (PPO)
![Email Prescription and/or Health Benefit details for Advantra Silver Plus (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$67.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $4,262.59 |
Browse Plan Formulary |
Freedom Blue PPO HD Rx (PPO)
![Email Prescription and/or Health Benefit details for Freedom Blue PPO HD Rx (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$70.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | None | $4,381.97 |
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 |
Geisinger Gold Preferred Advantage Rx (PPO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Preferred Advantage Rx (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$70.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P | $4,305.27 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Preferred Advantage Rx (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$70.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P | $4,305.27 |
Browse Plan Formulary |
SeniorBlue - Option 2 (PPO)
![Email Prescription and/or Health Benefit details for SeniorBlue - Option 2 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$72.40 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P | $4,498.73 |
Browse Plan Formulary |
Freedom Blue PPO ValueRx (PPO)
![Email Prescription and/or Health Benefit details for Freedom Blue PPO ValueRx (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | None | $4,381.97 |
Browse Plan Formulary |
Advantra Gold (PPO)
![Email Prescription and/or Health Benefit details for Advantra Gold (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$116.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $4,262.59 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Premier Plan (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$124.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $4,477.92 |
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 |
Geisinger Gold Classic Advantage Rx (HMO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Classic Advantage Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P | $4,300.68 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Classic Advantage Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P | $4,187.51 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Classic Advantage Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P | $4,187.51 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Classic Advantage Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P | $4,300.68 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
![Email Prescription and/or Health Benefit details for Geisinger Gold Classic Advantage Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$124.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | P | $4,300.68 |
Browse Plan Formulary |
Aetna Medicare Select Plus Plan (PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Select Plus Plan (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$139.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $4,263.57 |
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 |
SeniorBlue - Option 1 (PPO)
![Email Prescription and/or Health Benefit details for SeniorBlue - Option 1 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$191.90 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P | $4,498.73 |
Browse Plan Formulary |
Freedom Blue PPO Standard (PPO)
![Email Prescription and/or Health Benefit details for Freedom Blue PPO Standard (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$246.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | None | $4,381.97 |
Browse Plan Formulary |
Freedom Blue PPO Deluxe (PPO)
![Email Prescription and/or Health Benefit details for Freedom Blue PPO Deluxe (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$296.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | None | $4,381.97 |
Browse Plan Formulary |