LUPRON DEPOT 22.5 MG 3MO KIT SYRINGEKIT (1.5 ML ) (NDC: 00074334603)
2018 Medicare Prescription Drug Plan (MAPD) Information
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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 HealthyValue (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | None | $4,443.73 |
Browse Plan Formulary |
BCN Advantage HMO HealthyValue (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | None | $4,443.73 |
Browse Plan Formulary |
BCN Advantage HMO HealthyValue (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | None | $4,275.95 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $4,635.99 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $4,259.36 |
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 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $4,443.73 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $4,264.79 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $4,320.19 |
Browse Plan Formulary |
HAP Senior Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | n/a | None | $4,623.40 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | None | $4,457.80 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | None | $4,332.26 |
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 Key (HMO-POS)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | None | $4,234.33 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | None | $4,232.58 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | None | $4,489.09 |
Browse Plan Formulary |
HAP Senior Plus Option 1 (PPO)
|
$15.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
25% | n/a | None | $4,623.40 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | None | $4,489.09 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | None | $4,457.80 |
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)
|
$18.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | None | $4,332.26 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | None | $4,234.33 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | None | $4,232.58 |
Browse Plan Formulary |
HumanaChoice R3887-002 (Regional PPO)
|
$20.00 |
$405 |
to be determined |
4 |
Non-Preferred Drug |
25% | 25% | P Q:1 /90Days | $4,274.16 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$23.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | None | $4,443.73 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$23.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | None | $4,275.95 |
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 HealthySaver (HMO)
|
$23.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | None | $4,443.73 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$29.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $4,259.36 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$29.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $4,264.79 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$29.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $4,443.73 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$29.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $4,300.29 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$29.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $4,367.22 |
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 Value (HMO-POS)
|
$38.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | None | $4,489.09 |
Browse Plan Formulary |
HAP Senior Plus Option 1 (HMO-POS)
|
$45.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | n/a | None | $4,623.40 |
Browse Plan Formulary |
BCN Advantage HMO ConnectedCare (HMO)
|
$56.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,275.95 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$63.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | None | $4,457.80 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$63.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | None | $4,332.26 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$63.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | None | $4,234.33 |
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)
|
$63.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | None | $4,232.58 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$63.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | None | $4,489.09 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$84.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $4,300.29 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$84.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $4,367.22 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$84.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $4,259.36 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$84.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $4,443.73 |
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 |
Medicare Plus Blue PPO Vitality (PPO)
|
$84.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $4,264.79 |
Browse Plan Formulary |
HAP Senior Plus Option 2 (HMO-POS)
|
$85.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | n/a | None | $4,623.40 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$92.00 |
$115 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P | $4,623.43 |
Browse Plan Formulary |
HAP Senior Plus Option 2 (PPO)
|
$118.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | n/a | None | $4,623.40 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$122.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,489.09 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$137.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,443.73 |
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 |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$137.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,264.79 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$137.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,320.19 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$137.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,635.99 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$137.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,259.36 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$151.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,232.58 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$151.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,489.09 |
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)
|
$151.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,457.80 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$151.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,332.26 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$151.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,234.33 |
Browse Plan Formulary |
HAP Senior Plus Option 3 (HMO-POS)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | n/a | None | $4,623.40 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$179.50 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | None | $4,443.73 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$179.50 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | None | $4,264.79 |
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 |
Medicare Plus Blue PPO Signature (PPO)
|
$179.50 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | None | $4,300.29 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$179.50 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | None | $4,367.22 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$179.50 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | None | $4,259.36 |
Browse Plan Formulary |
HAP Senior Plus Option 3 (PPO)
|
$190.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | n/a | None | $4,623.40 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$262.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,367.22 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$262.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,259.36 |
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)
|
$262.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,443.73 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$262.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,264.79 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$262.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,300.29 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$278.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,320.19 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$278.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,635.99 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$278.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,259.36 |
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)
|
$278.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,443.73 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$278.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $4,264.79 |
Browse Plan Formulary |