SULFACETAMIDE SODIUM OPHTHALMIC SOLUTION USP 10% 15 ML BOT (15 ML BOT) (NDC: 24208067004)
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 Mosaic (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$4.00 | $8.00 | None | $39.55 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$6.00 | $12.00 | None | $39.55 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$8.00 | $16.00 | None | $39.55 |
Browse Plan Formulary |
Access Medicare Gold (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$0.00 | $0.00 | None | $48.83 |
Browse Plan Formulary |
Amerivantage Balance + Rx (HMO)
|
$0.00 |
$0 | Some Generics | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $45.64 |
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 |
Amerivantage Classic Choice + Rx Plan (HMO-POS)
|
$0.00 |
$0 | Some Generics | 1 |
Preferred Generic |
$3.00 | $6.00 | None | $45.64 |
Browse Plan Formulary |
Easy Choice Diamond Rewards (HMO SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $51.90 |
Browse Plan Formulary |
Easy Choice Diamond Rewards COPD (HMO SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $51.90 |
Browse Plan Formulary |
Easy Choice Rewards (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $51.90 |
Browse Plan Formulary |
Easy Choice Value (HMO)
|
$0.00 |
$0 | Many Generics | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $51.90 |
Browse Plan Formulary |
Elderplan Classic: Zero Premium (HMO)
|
$0.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$4.00 | $10.00 | None | $49.87 |
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 |
Empire MediBlue Plus (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $15.00 | None | $51.12 |
Browse Plan Formulary |
Fidelis Medicare $0 Premium (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $42.02 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$0.00 | $0.00 | None | $41.23 |
Browse Plan Formulary |
Healthfirst Jade Benefits Plan (HMO)
|
$0.00 |
$0 | Many Generics, Few Brands | 1 |
Generic |
$0.00 | $0.00 | None | $41.23 |
Browse Plan Formulary |
Liberty Health Advantage Preferred Choice (HMO)
|
$0.00 |
$0 | All Generics | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $48.00 |
Browse Plan Formulary |
PPO II (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$5.00 | $10.00 | None | $50.04 |
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 |
Touchstone Health Medicare Freedom (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$6.00 | $15.00 | None | $48.00 |
Browse Plan Formulary |
Touchstone Health Medicare Power (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$0.00 | $0.00 | None | $48.00 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (Regional PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$6.00 | $12.00 | None | $39.08 |
Browse Plan Formulary |
VIP (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$5.00 | $10.00 | None | $50.04 |
Browse Plan Formulary |
VIP (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$5.00 | $10.00 | None | $50.04 |
Browse Plan Formulary |
VIP (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$5.00 | $10.00 | None | $50.04 |
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 |
VIP Essential (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$5.00 | $10.00 | None | $50.04 |
Browse Plan Formulary |
VIP Essential (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$5.00 | $10.00 | None | $50.04 |
Browse Plan Formulary |
VIP Essential (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$5.00 | $10.00 | None | $50.04 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Enhanced (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$1.00 | $2.50 | None | $43.24 |
Browse Plan Formulary |
WellCare Choice (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$0.00 | $0.00 | None | $52.13 |
Browse Plan Formulary |
WellCare Rx (HMO)
|
$1.60 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$8.00 | $0.00 | None | $52.13 |
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 Liberty (HMO SNP)
|
$20.60 |
$325* | No additional gap coverage, only the Donut Hole Discount | 1* |
Generic |
$0.00 | $0.00 | None | $52.77 |
Browse Plan Formulary |
WellCare Advocate Complete (HMO SNP)
|
$28.40 |
$325* | No additional gap coverage, only the Donut Hole Discount | 1* |
Generic |
$0.00 | $0.00 | None | $51.37 |
Browse Plan Formulary |
MetroPlus Platinum (HMO)
|
$34.70 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $41.64 |
Browse Plan Formulary |
Healthfirst Increased Benefits Plan (HMO)
|
$35.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $41.23 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$35.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $38.66 |
Browse Plan Formulary |
Touchstone Health Medicare Total (HMO)
|
$38.60 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$0.00 | $0.00 | None | $48.00 |
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 |
HHH Choices Gold (HMO SNP)
|
$39.70 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $49.79 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Preferred (HMO SNP)
|
$40.10 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $43.24 |
Browse Plan Formulary |
Elderplan Advantage For Nursing Home Residents (HMO SNP)
|
$40.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $49.87 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$40.40 |
$325* | No additional gap coverage, only the Donut Hole Discount | 1* |
Generic |
$0.00 | $0.00 | None | $52.13 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$41.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
n/a | n/a | None | $39.12 |
Browse Plan Formulary |
GuildNet Health Advantage (HMO-POS SNP)
|
$41.60 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $50.04 |
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 |
MetroPlus Advantage Plan (HMO SNP)
|
$41.70 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $41.64 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete LP (HMO SNP)
|
$42.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $39.55 |
Browse Plan Formulary |
Healthfirst AssuredCare (HMO SNP)
|
$43.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $41.23 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO SNP)
|
$43.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
n/a | n/a | None | $41.23 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO SNP)
|
$43.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $41.23 |
Browse Plan Formulary |
Healthfirst Maximum Plan (HMO SNP)
|
$43.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
n/a | n/a | None | $41.23 |
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 |
MetroPlus Select Plan (HMO SNP)
|
$43.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
n/a | n/a | None | $41.64 |
Browse Plan Formulary |
Access Medicare Pearl (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $48.83 |
Browse Plan Formulary |
Access Medicare Platinum (HMO)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $48.83 |
Browse Plan Formulary |
Access Medicare Silver (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $48.83 |
Browse Plan Formulary |
Affinity Medicare Solutions (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $44.83 |
Browse Plan Formulary |
Affinity Medicare Ultimate (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
0% | 0% | None | $44.83 |
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 |
Amerivantage Specialty + Rx (HMO SNP)
|
$43.20 |
$325* | Many Generics, Few Brands | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $45.64 |
Browse Plan Formulary |
ArchCare - Inst and IE SNP - All Counties (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $41.47 |
Browse Plan Formulary |
CenterLight Direct Complete Plan (HMO SNP)
|
$43.20 |
$325* | No additional gap coverage, only the Donut Hole Discount | 1* |
Generic |
$7.25 | $21.75 | None | $52.40 |
Browse Plan Formulary |
CenterLight Direct Total Plan (HMO SNP)
|
$43.20 |
$185* | No additional gap coverage, only the Donut Hole Discount | 1* |
Generic |
$8.00 | $24.00 | None | $52.40 |
Browse Plan Formulary |
Dual Eligible (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$4.00 | $8.00 | None | $50.04 |
Browse Plan Formulary |
Dual Eligible (PPO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$4.00 | $8.00 | None | $50.04 |
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 |
Elderplan Extra Help (HMO)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $49.87 |
Browse Plan Formulary |
Elderplan For Medicaid Beneficiaries (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $49.87 |
Browse Plan Formulary |
Elderplan Medicaid Advantage (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $49.87 |
Browse Plan Formulary |
Elderplan Plus Long Term Care (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $49.87 |
Browse Plan Formulary |
Fidelis Dual Advantage (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $42.02 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO SNP)
|
$43.20 |
$320* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $42.02 |
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 |
Fidelis Long Term Care Advantage (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $42.02 |
Browse Plan Formulary |
Fidelis Medicaid Advantage Plus (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $42.02 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
|
$43.20 |
$320* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $42.02 |
Browse Plan Formulary |
GuildNet Gold (HMO-POS SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
n/a | n/a | None | $50.04 |
Browse Plan Formulary |
Liberty Health Advantage Dual Power (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $48.00 |
Browse Plan Formulary |
Senior Whole Health of New York (HMO SNP)
|
$43.20 |
$325* | No additional gap coverage, only the Donut Hole Discount | 1* |
Generic |
$0.00 | $0.00 | None | $50.67 |
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 |
Aetna Medicare Value Plan (HMO)
|
$50.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$6.00 | $12.00 | None | $15.48 |
Browse Plan Formulary |
PPO III (PPO)
|
$54.50 |
$0 | All Generics | 1 |
Preferred Generic |
$5.00 | $10.00 | None | $50.04 |
Browse Plan Formulary |
MetroPlus Medicare Partnership in Care Plan (HMO SNP)
|
$67.10 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $41.64 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Maximum (HMO SNP)
|
$78.50 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
n/a | n/a | None | $43.24 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (HMO)
|
$80.00 |
$0 | Some Generics | 1 |
Preferred Generic |
$6.00 | $12.00 | None | $15.48 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$85.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$6.00 | $12.00 | None | $16.09 |
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 |
VNSNY CHOICE Total (HMO SNP)
|
$95.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
n/a | n/a | None | $43.24 |
Browse Plan Formulary |
PPO High Option (PPO)
|
$132.50 |
$0 | All Generics | 1 |
Preferred Generic |
$5.00 | $10.00 | None | $50.04 |
Browse Plan Formulary |
VIP High Option (HMO)
|
$157.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$5.00 | $10.00 | None | $50.04 |
Browse Plan Formulary |
VIP High Option (HMO)
|
$157.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$5.00 | $10.00 | None | $50.04 |
Browse Plan Formulary |
VIP High Option (HMO)
|
$157.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$5.00 | $10.00 | None | $50.04 |
Browse Plan Formulary |