LOTEMAX 0.5% EYE DROPS (10 ML BOTDR) (NDC: 24208029910)
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 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $125.00 | None | $270.20 |
Browse Plan Formulary |
AARP MedicareComplete Choice (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $125.00 | None | $270.22 |
Browse Plan Formulary |
AARP MedicareComplete Choice Plan 2 (Regional PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $125.00 | None | $270.11 |
Browse Plan Formulary |
AARP MedicareComplete Plus (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $125.00 | None | $270.20 |
Browse Plan Formulary |
Amerivantage Classic+ Rx Plan (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$35.00 | $70.00 | None | $270.12 |
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 (HMO)
|
$0.00 |
$0 | All Generics | 3 |
Preferred Brand |
$45.00 | $135.00 | None | $270.77 |
Browse Plan Formulary |
BlueMedicare Regional PPO (Regional PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $135.00 | None | $270.79 |
Browse Plan Formulary |
CareDirect (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$55.00 | $155.00 | None | $270.43 |
Browse Plan Formulary |
CareFree (HMO)
|
$0.00 |
$0 | Few Generics, Few Brands | 4 |
Non-Preferred Brand |
$55.00 | $155.00 | None | $270.44 |
Browse Plan Formulary |
CareOne (HMO)
|
$0.00 |
$0 | Some Generics, Few Brands | 4 |
Non-Preferred Brand |
$80.00 | $230.00 | None | $270.51 |
Browse Plan Formulary |
CareOne PLUS (HMO)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$55.00 | $155.00 | None | $270.44 |
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 |
Clear Skies (HMO SNP)
|
$0.00 |
$0 | All Generics | 3 |
Non-Preferred Brand |
$40.00 | $120.00 | None | $279.05 |
Browse Plan Formulary |
Coventry Advantra Ideal (HMO)
|
$0.00 |
$0 | Many Generics | 2 |
Preferred Brand |
$20.00 | $40.00 | None | $282.06 |
Browse Plan Formulary |
Coventry Advantra Select Plus (HMO-POS)
|
$0.00 |
$0 | Many Generics | 2 |
Preferred Brand |
$30.00 | $60.00 | None | $282.00 |
Browse Plan Formulary |
Freedom Medicare Plan Rx (HMO)
|
$0.00 |
$0 | Many Generics | 3 |
Non-Preferred Brand |
$60.00 | $120.00 | None | $263.83 |
Browse Plan Formulary |
Freedom Savings Plan Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$65.00 | $130.00 | None | $263.95 |
Browse Plan Formulary |
Freedom VIP Care (HMO SNP)
|
$0.00 |
$0 | Many Generics | 3 |
Non-Preferred Brand |
$60.00 | $120.00 | None | $263.81 |
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 COPD (HMO SNP)
|
$0.00 |
$0 | Many Generics | 3 |
Non-Preferred Brand |
$60.00 | $120.00 | None | $263.81 |
Browse Plan Formulary |
Freedom VIP Savings (HMO SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$60.00 | $120.00 | None | $263.81 |
Browse Plan Formulary |
Freedom VIP Savings COPD (HMO SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$60.00 | $120.00 | None | $263.81 |
Browse Plan Formulary |
Humana Gold Plus H1036-025 (HMO)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$55.00 | $155.00 | None | $270.25 |
Browse Plan Formulary |
Humana Gold Plus H1036-141 (HMO)
|
$0.00 |
$0 | Few Generics, Few Brands | 4 |
Non-Preferred Brand |
$55.00 | $155.00 | None | $270.54 |
Browse Plan Formulary |
Humana Gold Plus SNP-DB H1036-160 (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$55.00 | $155.00 | None | $270.54 |
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 Reader''s Digest Healthy Living Plan (Regional PPO)
|
$0.00 |
$0 | Few Generics, Few Brands | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $270.09 |
Browse Plan Formulary |
Optimum Diamond Rewards (HMO-POS SNP)
|
$0.00 |
$0 | Many Generics | 3 |
Non-Preferred Brand |
$50.00 | $100.00 | None | $263.72 |
Browse Plan Formulary |
Optimum Diamond Rewards COPD (HMO-POS SNP)
|
$0.00 |
$0 | Many Generics | 3 |
Non-Preferred Brand |
$50.00 | $100.00 | None | $263.72 |
Browse Plan Formulary |
Optimum Gold Rewards Plan (HMO-POS)
|
$0.00 |
$0 | Many Generics | 3 |
Non-Preferred Brand |
$69.00 | $138.00 | None | $263.67 |
Browse Plan Formulary |
Optimum Platinum Plan (HMO-POS)
|
$0.00 |
$0 | Many Generics | 3 |
Non-Preferred Brand |
$60.00 | $120.00 | None | $263.67 |
Browse Plan Formulary |
PUP PLUS (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$35.00 | $70.00 | None | $270.45 |
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 |
PUP SIMPLE (HMO)
|
$0.00 |
$0 | Many Generics | 2 |
Preferred Brand |
$20.00 | $40.00 | None | $270.45 |
Browse Plan Formulary |
Simply Level (HMO SNP)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$55.00 | n/a | None | $268.16 |
Browse Plan Formulary |
Simply More (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$55.00 | n/a | None | $268.15 |
Browse Plan Formulary |
Sunrise (HMO)
|
$0.00 |
$0 | All Generics | 3 |
Non-Preferred Brand |
$40.00 | $120.00 | None | $279.05 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$0 | All Generics | 3 |
Non-Preferred Brand |
$55.00 | $110.00 | None | $274.98 |
Browse Plan Formulary |
WellCare Essential (HMO)
|
$0.00 |
$0 | All Generics | 3 |
Non-Preferred Brand |
$60.00 | $120.00 | None | $275.58 |
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 |
WellCare Value (HMO-POS)
|
$0.00 |
$0 | All Generics | 3 |
Non-Preferred Brand |
$55.00 | $110.00 | None | $275.61 |
Browse Plan Formulary |
PUP EXTRA (HMO SNP)
|
$4.90 |
$0 | to be determined | 2 |
Tier 2 |
$0.00 | $0.00 | None | $270.13 |
Browse Plan Formulary |
Sunny Days (HMO SNP)
|
$5.00 |
$325 | to be determined | 3 |
Tier 3 |
15% | 15% | None | $279.05 |
Browse Plan Formulary |
WellCare Select (HMO-POS SNP)
|
$8.50 |
$325 | to be determined | 3 |
Tier 3 |
$95.00 | $190.00 | None | $274.96 |
Browse Plan Formulary |
WellCare Liberty (HMO SNP)
|
$8.70 |
$325 | to be determined | 3 |
Tier 3 |
$95.00 | $190.00 | None | $275.11 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$12.10 |
$325 | to be determined | 3 |
Tier 3 |
$95.00 | $190.00 | None | $275.11 |
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 SNP-DE H1036-102 (HMO SNP)
|
$14.70 |
$325 | to be determined | 4 |
Tier 4 |
$95.00 | $275.00 | None | $270.54 |
Browse Plan Formulary |
Coventry Advantra Maximum (HMO SNP)
|
$17.70 |
$0 | to be determined | 2 |
Tier 2 |
$45.00 | $90.00 | None | $286.55 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$18.70 |
$325* | to be determined | 2* |
Tier 2 |
$0.00 | $0.00 | None | $268.75 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-161 (HMO SNP)
|
$19.70 |
$325 | to be determined | 4 |
Tier 4 |
$95.00 | $275.00 | None | $270.53 |
Browse Plan Formulary |
CareNeeds PLUS (HMO SNP)
|
$19.80 |
$325 | to be determined | 4 |
Tier 4 |
$95.00 | $275.00 | None | $270.51 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete LP (HMO SNP)
|
$22.10 |
$325 | to be determined | 3 |
Tier 3 |
15% | 15% | None | $270.23 |
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 |
Freedom Medi-Medi Full (HMO SNP)
|
$23.10 |
$325 | to be determined | 1 |
Tier 1 |
n/a | n/a | None | $263.85 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$23.80 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $270.20 |
Browse Plan Formulary |
Sunshine State Health Plan (HMO SNP)
|
$24.00 |
$325 | to be determined | 2 |
Tier 2 |
$45.00 | $45.00 | None | $273.46 |
Browse Plan Formulary |
CareNeeds (HMO SNP)
|
$24.10 |
$325 | to be determined | 4 |
Tier 4 |
$95.00 | $275.00 | None | $270.44 |
Browse Plan Formulary |
Amerivantage Specialty + Rx (HMO SNP)
|
$24.70 |
$325 | Some Generics | 3 |
Preferred Brand |
25% | 25% | None | $270.12 |
Browse Plan Formulary |
Freedom Medi-Medi Partial (HMO SNP)
|
$24.70 |
$325 | to be determined | 1 |
Tier 1 |
15% | 15% | None | $263.85 |
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 Emerald Full (HMO SNP)
|
$24.80 |
$325 | to be determined | 1 |
Tier 1 |
n/a | n/a | None | $263.83 |
Browse Plan Formulary |
Optimum Emerald Partial (HMO SNP)
|
$24.80 |
$325 | to be determined | 1 |
Tier 1 |
15% | 15% | None | $263.83 |
Browse Plan Formulary |
Simply Care (HMO SNP)
|
$24.80 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$75.00 | n/a | None | $268.09 |
Browse Plan Formulary |
Simply Comfort (HMO SNP)
|
$24.80 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$75.00 | n/a | None | $268.09 |
Browse Plan Formulary |
Simply Complete (HMO SNP)
|
$24.80 |
$0 | to be determined | 4 |
Tier 4 |
$75.00 | n/a | None | $268.16 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete EV (HMO SNP)
|
$24.80 |
$325 | to be determined | 3 |
Tier 3 |
15% | 15% | None | $270.28 |
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 |
UnitedHealthcare Dual Complete RP (Regional PPO SNP)
|
$24.80 |
$325 | to be determined | 3 |
Tier 3 |
15% | 15% | None | $270.11 |
Browse Plan Formulary |
HumanaChoice R5826-005 (Regional PPO)
|
$28.10 |
$0 | Few Generics, Few Brands | 4 |
Non-Preferred Brand |
$85.00 | $245.00 | None | $270.09 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$33.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $90.00 | None | $271.91 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$39.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $90.00 | None | $272.39 |
Browse Plan Formulary |
Day Break (HMO)
|
$77.50 |
$0 | All Generics | 3 |
Non-Preferred Brand |
$60.00 | $180.00 | None | $279.05 |
Browse Plan Formulary |
Humana Gold Choice H8145-061 (PFFS)
|
$102.00 |
$0 | Few Generics, Few Brands | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $270.05 |
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 PPO (PPO)
|
$152.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $135.00 | None | $270.96 |
Browse Plan Formulary |