ILEVRO 0.3% OPHTH DROPS (1.7 ML ) (NDC: 00065175007)
2013 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 SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 |
Some Generics |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $153.12 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 |
Some Generics |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $153.12 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 4 (HMO)
|
$0.00 |
$0 |
Some Generics |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $153.12 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 |
Some Generics |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $159.79 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 |
Some Generics |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $159.79 |
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 |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
Many Generics |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | Q:2 /30Days | $152.29 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
Many Generics |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | Q:2 /30Days | $152.29 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 |
Many Generics |
3 |
Non-Preferred Brand |
$70.00 | $140.00 | Q:2 /30Days | $152.29 |
Browse Plan Formulary |
Brand New Day (HMO)
|
$0.00 |
$0 |
Many Generics |
2 |
Brand |
$40.00 | $80.00 | None | $151.05 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
Many Generics |
3 |
Preferred Brand |
$40.00 | $80.00 | None | $151.04 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
Many Generics |
3 |
Preferred Brand |
$40.00 | $80.00 | None | $151.04 |
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 |
Freedom VIP Care (HMO SNP)
|
$0.00 |
$0 |
Many Generics |
3 |
Preferred Brand |
$40.00 | $80.00 | None | $151.05 |
Browse Plan Formulary |
Freedom VIP Care (HMO SNP)
|
$0.00 |
$0 |
Many Generics |
3 |
Preferred Brand |
$40.00 | $80.00 | None | $151.05 |
Browse Plan Formulary |
Freedom VIP Care COPD (HMO SNP)
|
$0.00 |
$0 |
Many Generics |
3 |
Preferred Brand |
$40.00 | $80.00 | None | $151.05 |
Browse Plan Formulary |
Freedom VIP Care COPD (HMO SNP)
|
$0.00 |
$0 |
Many Generics |
3 |
Preferred Brand |
$40.00 | $80.00 | None | $151.05 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Many Generics |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $157.78 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 |
Many Generics |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $157.78 |
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 Healthy Heart Plan 1 (HMO)
|
$0.00 |
$0 |
Many Generics |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $157.78 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 |
Many Generics |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $157.78 |
Browse Plan Formulary |
Health Net Seniority Plus Ruby Plan 1 (HMO)
|
$0.00 |
$0 |
Many Generics |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $157.78 |
Browse Plan Formulary |
Humana Gold Plus H0108-008 (HMO)
|
$0.00 |
$0 |
Some Generics, Few Brands |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $152.37 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $130.00 | None | $165.96 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $130.00 | None | $165.96 |
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 |
All Generics, Few Brands |
4 |
Non-Preferred Brand |
$60.00 | $120.00 | None | $165.96 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage San Diego (HMO)
|
$0.00 |
$0 |
All Generics, Few Brands |
4 |
Non-Preferred Brand |
$65.00 | $130.00 | None | $165.96 |
Browse Plan Formulary |
Sharp SecureHorizons Plan by UnitedHealthcare (HMO)
|
$0.00 |
$0 |
Some Generics |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $153.12 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$11.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $165.96 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$11.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $165.96 |
Browse Plan Formulary |
Health Net Healthy Heart Plan 2 (HMO)
|
$23.90 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $157.78 |
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 |
AARP MedicareComplete SecureHorizons Value (HMO)
|
$25.00 |
$0 |
Some Generics |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $153.12 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$26.90 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $153.12 |
Browse Plan Formulary |
Brand New Day (HMO SNP)
|
$29.80 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $151.05 |
Browse Plan Formulary |
Brand New Day D SNP (HMO SNP)
|
$29.80 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $151.05 |
Browse Plan Formulary |
Brand New Day HMO Extra Care (HMO)
|
$29.80 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $151.05 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$29.80 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $157.78 |
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 Amber II (HMO SNP)
|
$29.80 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $157.78 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$29.80 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $157.78 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$29.80 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$45.00 | $135.00 | None | $155.80 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$29.80 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$45.00 | $135.00 | None | $155.80 |
Browse Plan Formulary |
CommuniCare Advantage (HMO SNP)
|
$29.90 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Brand |
$60.00 | $180.00 | None | $154.45 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$29.90 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | 25% | None | $151.04 |
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 |
Freedom Plan (HMO SNP)
|
$29.90 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | 25% | None | $151.04 |
Browse Plan Formulary |
L.A. Care Health Plan Medicare Advantage (HMO SNP)
|
$29.90 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
n/a | n/a | None | $151.01 |
Browse Plan Formulary |
Humana Gold Plus H0108-009 (HMO-POS)
|
$39.00 |
$0 |
Few Generics, Few Brands |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $152.37 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Premier (HMO)
|
$69.00 |
$0 |
Some Generics |
3 |
Preferred Brand |
$42.00 | $116.00 | None | $153.12 |
Browse Plan Formulary |
Health Net Seniority Plus Ruby Plan 2 (HMO)
|
$69.00 |
$0 |
Many Generics |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $157.78 |
Browse Plan Formulary |
Health Net Violet (PPO)
|
$82.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $157.78 |
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 Ruby (HMO)
|
$182.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $157.78 |
Browse Plan Formulary |