FIRMAGON 2 X 120 MG KIT (NDC: 55566840301)
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 | $1,390.83 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $1,411.27 |
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 | $1,404.44 |
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 | $1,404.44 |
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 | $1,402.98 |
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, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | 33% | None | $1,408.66 |
Browse Plan Formulary |
BlueMedicare HMO MyTime (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | 33% | None | $1,408.13 |
Browse Plan Formulary |
CareDirect (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $1,432.07 |
Browse Plan Formulary |
CareHeart (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $1,432.07 |
Browse Plan Formulary |
CareOne (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $1,432.07 |
Browse Plan Formulary |
Coventry Summit Ideal (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Specialty Tier |
33% | n/a | P | $1,395.52 |
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 | 4 |
Specialty Tier |
33% | n/a | P | $1,394.62 |
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 | $1,373.24 |
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 | $1,370.13 |
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 | $1,370.13 |
Browse Plan Formulary |
HealthSun HealthAdvantage Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $1,394.72 |
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 | $1,432.07 |
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 | $1,432.07 |
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 | $1,432.07 |
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 | $1,432.07 |
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 | $1,402.40 |
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 | $1,407.70 |
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 | $1,391.14 |
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 |
Optimum Gold Rewards Plan (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Specialty Tier |
33% | 33% | P | $1,377.24 |
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 | $1,377.24 |
Browse Plan Formulary |
Preferred Choice Broward (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Specialty Tier |
33% | 33% | P | $1,391.14 |
Browse Plan Formulary |
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 | $1,432.07 |
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 | $1,432.07 |
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% | None | $1,410.61 |
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 | $1,389.81 |
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 | $1,391.83 |
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 | $1,389.81 |
Browse Plan Formulary |
Coventry Summit Maximum (HMO SNP)
|
$24.60 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Specialty Tier |
33% | n/a | P | $1,402.92 |
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 | $1,375.66 |
Browse Plan Formulary |
Freedom Medi-Medi Partial (HMO SNP)
|
$25.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | P | $1,375.66 |
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 |
HealthSun MediMax (HMO)
|
$25.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P | $1,392.03 |
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 | $1,375.66 |
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 | $1,375.66 |
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 | $1,432.40 |
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 | $1,390.83 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$35.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $1,411.27 |
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 R5826-005 (Regional PPO)
|
$39.40 |
$100 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
30% | n/a | P | $1,407.70 |
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 | $1,402.40 |
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 | $1,407.70 |
Browse Plan Formulary |
BlueMedicare PPO (PPO)
|
$127.10 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | 33% | None | $1,410.58 |
Browse Plan Formulary |
Aetna Medicare Select Plus Plan (HMO)
|
$139.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $1,411.27 |
Browse Plan Formulary |
Aetna Medicare Select Plus Plan (PPO)
|
$139.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $1,411.07 |
Browse Plan Formulary |