LUPRON DEPOT 3.75 MG KIT (1 ML ) (NDC: 00074364103)
2019 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 |
AARP MedicareComplete SecureHorizons Focus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | 33% | P | $1,390.43 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | 33% | P | $1,390.43 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $1,374.08 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $1,374.08 |
Browse Plan Formulary |
Alignment Health Plan Heart & Diabetes (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $1,319.49 |
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 |
Alignment Health Plan My Choice (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $1,312.30 |
Browse Plan Formulary |
Alignment Health Plan Platinum (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $1,319.49 |
Browse Plan Formulary |
Anthem Breathe (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $1,255.02 |
Browse Plan Formulary |
Anthem Care On Site (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $1,255.02 |
Browse Plan Formulary |
Anthem Diabetes (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $1,255.02 |
Browse Plan Formulary |
Anthem ESRD (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $1,255.02 |
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 |
Anthem Heart (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $1,255.02 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $1,255.02 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $1,252.58 |
Browse Plan Formulary |
Anthem StartSmart Plus (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $1,269.02 |
Browse Plan Formulary |
Anthem Value Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $1,255.02 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 6 |
Specialty Tier |
33% | n/a | None | $1,274.68 |
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 |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 6 |
Specialty Tier |
33% | n/a | None | $1,274.68 |
Browse Plan Formulary |
Brand New Day Bridges Care Plan (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $1,274.87 |
Browse Plan Formulary |
Brand New Day Classic Care I Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $1,274.87 |
Browse Plan Formulary |
Brand New Day Classic Care II Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $1,274.87 |
Browse Plan Formulary |
Brand New Day Embrace Care Plan (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $1,274.87 |
Browse Plan Formulary |
Brand New Day Embrace Care Plan (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $1,274.87 |
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 |
Brand New Day Harmony Care Plan (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $1,274.87 |
Browse Plan Formulary |
Central Health Focus Plan (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $1,263.02 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $1,263.02 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $1,314.42 |
Browse Plan Formulary |
Golden State (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | 33% | P Q:1 /28Days | $1,358.87 |
Browse Plan Formulary |
Golden State (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | 33% | P Q:1 /28Days | $1,326.72 |
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 |
Health Net Gold Select (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $1,329.00 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $1,305.53 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $1,329.00 |
Browse Plan Formulary |
Heart First (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $1,252.58 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | P Q:1 /30Days | $1,365.93 |
Browse Plan Formulary |
Inter Valley Health Plan Service To Seniors (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $1,290.55 |
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 |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | None | $1,321.48 |
Browse Plan Formulary |
OneCare Connect (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Brand Drugs |
0% | n/a | P | $1,359.58 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $1,255.02 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $1,252.58 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $1,269.27 |
Browse Plan Formulary |
Easy Choice Rx (HMO)
|
$12.00 |
$415 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | n/a | P | $1,314.42 |
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 |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$12.50 |
$0 | to be determined | 3 |
Preferred Brand |
$47.00 | $94.00 | None | $1,321.48 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$16.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $1,329.00 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$16.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $1,305.53 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Assure (HMO)
|
$16.10 |
$415 | No additional gap coverage, only the Donut Hole Discount | 5 |
All Formulary Drugs |
25% | 25% | P | $1,390.32 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$25.00 |
$415 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P | $1,314.42 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Premier (HMO)
|
$25.20 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | 33% | P | $1,390.43 |
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 |
SCAN Prime (HMO)
|
$26.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $1,252.58 |
Browse Plan Formulary |
Alignment Health Plan CalPlus (HMO)
|
$30.50 |
$415 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $1,312.93 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$33.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:1 /30Days | $1,365.93 |
Browse Plan Formulary |
OneCare (HMO SNP)
|
$33.70 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Brand |
$0.00 | n/a | P | $1,359.58 |
Browse Plan Formulary |
Anthem Connect Plus (HMO)
|
$34.70 |
$415 | No additional gap coverage, only the Donut Hole Discount | 5 |
All Formulary Drugs |
25% | 25% | P Q:1 /28Days | $1,269.02 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$34.80 |
$415 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | n/a | P Q:1 /28Days | $1,255.02 |
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 |
Brand New Day Bridges Choice Medi-Medi Plan (HMO SNP)
|
$34.80 |
$415 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $1,274.87 |
Browse Plan Formulary |
Brand New Day Classic Choice Medi-Medi Plan (HMO)
|
$34.80 |
$415 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $1,274.87 |
Browse Plan Formulary |
Brand New Day Dual Access Plan (HMO SNP)
|
$34.80 |
$415 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $1,274.87 |
Browse Plan Formulary |
Brand New Day Embrace Choice Medi-Medi Plan (HMO SNP)
|
$34.80 |
$415 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $1,274.87 |
Browse Plan Formulary |
Brand New Day Embrace Choice Medi-Medi Plan (HMO SNP)
|
$34.80 |
$415 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $1,274.87 |
Browse Plan Formulary |
Brand New Day Harmony Choice Plan (HMO SNP)
|
$34.80 |
$415 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $1,274.87 |
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 |
Brand New Day Select Care Plan (HMO SNP)
|
$34.80 |
$415 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $1,274.87 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$34.80 |
$415 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | n/a | None | $1,263.02 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$34.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
26% | n/a | None | $1,309.92 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
27% | n/a | None | $1,314.11 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
27% | n/a | None | $1,416.60 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
27% | n/a | None | $1,304.23 |
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 |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
26% | n/a | None | $1,314.11 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
26% | n/a | None | $1,416.60 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
26% | n/a | None | $1,304.23 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$34.80 |
$285 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
27% | n/a | None | $1,314.11 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier II (HMO)
|
$34.80 |
$280 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
27% | n/a | None | $1,314.11 |
Browse Plan Formulary |
Inter Valley Health Plan Value Preferred Choice (HMO)
|
$34.80 |
$415 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:1 /28Days | $1,290.06 |
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 |
SCAN Plus (HMO)
|
$34.80 |
$415 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P | $1,269.27 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$34.80 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $94.00 | None | $1,321.48 |
Browse Plan Formulary |
VillageHealth (HMO-POS SNP)
|
$34.80 |
$415 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P | $1,255.02 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$73.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $1,374.08 |
Browse Plan Formulary |
Anthem MediBlue Access (PPO)
|
$159.00 |
$370 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:1 /28Days | $1,252.58 |
Browse Plan Formulary |