LUPRON DEPOT 22.5 MG 3MO KIT [LUPRON] (1.5 ML ) (NDC: 00074334603)
2016 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 |
Aetna Better Health Premier Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | P | $3,792.60 |
Browse Plan Formulary |
AmeriHealth Caritas VIP Care PLUS (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | P | $3,745.28 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $3,706.63 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $3,916.53 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $3,706.63 |
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 Basic (HMO-POS)
|
$0.00 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $3,706.63 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $3,706.63 |
Browse Plan Formulary |
Fidelis SecureLife (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | P | $3,774.65 |
Browse Plan Formulary |
HAP Midwest MI Health Link (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | n/a | None | $3,860.65 |
Browse Plan Formulary |
Harbor Medicare (HMO)
|
$0.00 |
$240 |
to be determined |
5 |
Specialty Tier |
27% | n/a | P | $3,782.68 |
Browse Plan Formulary |
HealthPlus MedicarePlus Option 0 (HMO)
|
$0.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | 25% | Q:1 /84Days | $3,767.62 |
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 |
Meridian Prime (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P | $3,812.57 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $3,689.08 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $3,714.92 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $3,902.47 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $3,902.47 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $3,823.59 |
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 Ideal (PPO)
|
$15.00 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $3,902.47 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $3,823.59 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $3,689.08 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $3,714.92 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $3,902.47 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$20.50 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $3,706.63 |
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)
|
$20.50 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $3,916.53 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$20.50 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $3,706.63 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$20.50 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $3,706.63 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$20.50 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $3,706.63 |
Browse Plan Formulary |
HAP Midwest Health Plan (HMO SNP)
|
$33.50 |
$360 |
to be determined |
2 |
Brand |
25% | n/a | None | $3,863.35 |
Browse Plan Formulary |
Meridian Advantage Plan of Michigan (HMO SNP)
|
$33.50 |
$360 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | P | $3,812.57 |
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 |
BCN Advantage HMO ConnectedCare (HMO)
|
$47.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | None | $3,706.63 |
Browse Plan Formulary |
Harbor Medicare Select (HMO)
|
$47.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | P | $3,782.68 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$59.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$45.00 | $112.50 | None | $4,024.38 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$66.00 |
$75 |
to be determined |
5 |
Tier 5 |
31% | n/a | None | $3,823.59 |
Browse Plan Formulary |
HAP Senior Plus - Henry Ford (HMO)
|
$79.00 |
$200 |
to be determined |
3 |
Preferred Brand |
$45.00 | $112.50 | None | $4,023.50 |
Browse Plan Formulary |
McLaren Advantage Sapphire (HMO)
|
$81.00 |
$150 |
to be determined |
4 |
Specialty Tier |
29% | n/a | None | $3,859.71 |
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 |
McLaren Advantage Sapphire (HMO)
|
$81.00 |
$150 |
to be determined |
4 |
Specialty Tier |
29% | n/a | None | $3,857.44 |
Browse Plan Formulary |
Humana Gold Plus H8908-001 (HMO)
|
$89.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $290.00 | P Q:1 /90Days | $3,743.41 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75 |
to be determined |
5 |
Tier 5 |
31% | n/a | None | $3,823.59 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75 |
to be determined |
5 |
Tier 5 |
31% | n/a | None | $3,689.08 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75 |
to be determined |
5 |
Tier 5 |
31% | n/a | None | $3,714.92 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75 |
to be determined |
5 |
Tier 5 |
31% | n/a | None | $3,902.47 |
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)
|
$95.00 |
$75 |
to be determined |
5 |
Tier 5 |
31% | n/a | None | $3,902.47 |
Browse Plan Formulary |
HealthPlus MedicarePlus Option 1 (HMO)
|
$98.00 |
$100* |
to be determined |
5* |
Specialty Tier |
30% | 30% | Q:1 /84Days | $3,767.62 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$106.00 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $3,706.63 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$106.00 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $3,706.63 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$106.00 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $3,916.53 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$106.00 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $3,706.63 |
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)
|
$106.00 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $3,706.63 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$109.00 |
$100 |
to be determined |
3 |
Preferred Brand |
$45.00 | $112.50 | None | $4,024.38 |
Browse Plan Formulary |
McLaren Advantage Diamond (HMO)
|
$117.00 |
$150 |
to be determined |
4 |
Specialty Tier |
29% | n/a | None | $3,859.71 |
Browse Plan Formulary |
McLaren Advantage Diamond (HMO)
|
$117.00 |
$150 |
to be determined |
4 |
Specialty Tier |
29% | n/a | None | $3,857.44 |
Browse Plan Formulary |
HumanaChoice R5826-006 (Regional PPO)
|
$121.00 |
$360 |
to be determined |
4 |
Tier 4 |
25% | 25% | P Q:1 /90Days | $3,743.37 |
Browse Plan Formulary |
Alliance Medicare PPO (PPO)
|
$126.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$45.00 | $112.50 | None | $4,024.38 |
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)
|
$146.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $3,823.59 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$154.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | None | $3,706.63 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$154.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | None | $3,706.63 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$154.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | None | $3,706.63 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$154.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | None | $3,916.53 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$154.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | None | $3,706.63 |
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)
|
$169.00 |
$100 |
to be determined |
5 |
Specialty Tier |
30% | n/a | None | $3,706.63 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$169.00 |
$100 |
to be determined |
5 |
Specialty Tier |
30% | n/a | None | $3,706.63 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$169.00 |
$100 |
to be determined |
5 |
Specialty Tier |
30% | n/a | None | $3,706.63 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$169.00 |
$100 |
to be determined |
5 |
Specialty Tier |
30% | n/a | None | $3,916.53 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$169.00 |
$100 |
to be determined |
5 |
Specialty Tier |
30% | n/a | None | $3,706.63 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$193.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $3,902.47 |
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 Select (PPO)
|
$193.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $3,902.47 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$193.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $3,823.59 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$193.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $3,689.08 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$193.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $3,714.92 |
Browse Plan Formulary |
Alliance Medicare PPO (PPO)
|
$210.00 |
$150 |
to be determined |
3 |
Preferred Brand |
$40.00 | $100.00 | None | $4,024.38 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$220.00 |
$50 |
to be determined |
3 |
Preferred Brand |
$45.00 | $112.50 | None | $4,024.38 |
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)
|
$283.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | None | $3,706.63 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$283.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | None | $3,706.63 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$283.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | None | $3,916.53 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$283.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | None | $3,706.63 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$283.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | None | $3,706.63 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$294.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | None | $3,706.63 |
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)
|
$294.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | None | $3,916.53 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$294.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | None | $3,706.63 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$294.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | None | $3,706.63 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$294.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | None | $3,706.63 |
Browse Plan Formulary |