HydrOXYzine Hydrochloride 10mg/5mL 473 mL in 1 BOTTLE, PLASTIC (473 mL in 1 BOTTLE, PLAST ) (NDC: 50383079616)
2014 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 Choice Plan 2 (Regional PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | P | $27.82 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$0 |
Few Generics |
1 |
Generic |
$10.00 | $20.00 | P | $26.53 |
Browse Plan Formulary |
AvMed Medicare Choice (HMO)
|
$0.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | P | $32.89 |
Browse Plan Formulary |
AvMed Medicare Choice Elect (HMO)
|
$0.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$4.00 | $0.00 | P | $32.89 |
Browse Plan Formulary |
BlueMedicare HMO LifeTime (HMO)
|
$0.00 |
$0 |
Many Generics |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | P | $35.67 |
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 |
BlueMedicare HMO PrimeTime (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | P | $35.67 |
Browse Plan Formulary |
BlueMedicare Regional PPO (Regional PPO)
|
$0.00 |
$30 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | P | $34.59 |
Browse Plan Formulary |
Freedom Medicare Plan Rx (HMO)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | S | $33.86 |
Browse Plan Formulary |
Freedom VIP Care (HMO SNP)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | S | $33.86 |
Browse Plan Formulary |
Freedom VIP Care COPD (HMO SNP)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | S | $33.86 |
Browse Plan Formulary |
Freedom VIP Savings (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | S | $33.86 |
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 Savings COPD (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | S | $33.86 |
Browse Plan Formulary |
Healthy Advantage Plan (HMO)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | n/a | P | $30.35 |
Browse Plan Formulary |
Leon Medical Centers Health Plans - Leon Cares (HMO)
|
$0.00 |
$0 |
Many Generics |
1 |
Generic |
$0.00 | n/a | None | $25.70 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax (HMO-POS)
|
$0.00 |
$0 |
Many Generics |
3 |
Non-Preferred Brand |
$25.00 | n/a | P | $27.68 |
Browse Plan Formulary |
Optimum Gold Rewards Plan (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | S | $32.91 |
Browse Plan Formulary |
Optimum Platinum Plan (HMO-POS)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | S | $32.91 |
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 |
PHP (HMO SNP)
|
$0.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
25% | n/a | P | $29.83 |
Browse Plan Formulary |
Preferred Choice Dade (HMO-POS)
|
$0.00 |
$0 |
Many Generics |
3 |
Non-Preferred Brand |
$25.00 | $65.00 | P | $27.68 |
Browse Plan Formulary |
Preferred Complete Care (HMO)
|
$0.00 |
$0 |
Many Generics, Some Brands |
3 |
Non-Preferred Brand |
$25.00 | $65.00 | P | $27.68 |
Browse Plan Formulary |
Preferred Medical Plan Choice (HMO)
|
$0.00 |
$0 |
Many Generics, Many Brands |
1 |
Preferred Generic |
$0.00 | $0.00 | P | $33.81 |
Browse Plan Formulary |
Preferred Medical Plan Value (HMO)
|
$0.00 |
$0 |
Some Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | P | $33.81 |
Browse Plan Formulary |
Preferred Special Care Miami-Dade (HMO SNP)
|
$0.00 |
$0 |
Many Generics |
3 |
Non-Preferred Brand |
$25.00 | $65.00 | P | $27.68 |
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 |
Simply Clear (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
25% | n/a | P | $27.18 |
Browse Plan Formulary |
Simply Extra (HMO)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | P | $27.18 |
Browse Plan Formulary |
Simply Level (HMO SNP)
|
$0.00 |
$0 |
Many Generics, Few Brands |
1 |
Preferred Generic |
$0.00 | $0.00 | P | $27.18 |
Browse Plan Formulary |
Simply More (HMO)
|
$0.00 |
$0 |
All Generics, All Brands |
1 |
Preferred Generic |
$0.00 | $0.00 | P | $27.18 |
Browse Plan Formulary |
Simply Options (HMO-POS)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | P | $27.18 |
Browse Plan Formulary |
SunPlus Advantage Plan (HMO)
|
$0.00 |
$0 |
All Generics, All Brands |
1 |
Preferred Generic |
$0.00 | n/a | P | $30.35 |
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 |
SunPlus Diabetes Special Needs Plan (HMO SNP)
|
$0.00 |
$0 |
All Generics, All Brands |
1 |
Preferred Generic |
$0.00 | n/a | P | $30.35 |
Browse Plan Formulary |
WellCare Select (HMO SNP)
|
$11.60 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$4.00 | $8.00 | P | $31.45 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$12.80 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$7.00 | $14.00 | P | $31.78 |
Browse Plan Formulary |
WellCare Liberty (HMO SNP)
|
$17.80 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | P | $31.78 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$19.90 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | P | $27.54 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax Plus (HMO-POS SNP)
|
$20.60 |
$0 |
Many Generics |
3 |
Non-Preferred Brand |
25% | n/a | P | $27.49 |
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 |
Advantage by Sunshine Health (HMO SNP)
|
$21.00 |
$310* |
Many Generics |
1* |
Generic |
$0.00 | $0.00 | P | $33.32 |
Browse Plan Formulary |
Preferred Medicare Assist (HMO-POS SNP)
|
$21.20 |
$0 |
Many Generics |
3 |
Non-Preferred Brand |
25% | 25% | P | $27.49 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP (Regional PPO SNP)
|
$21.80 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | P | $27.82 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$22.00 |
$310* |
Many Generics, Few Brands |
1* |
Generic |
$0.00 | $0.00 | P | $31.01 |
Browse Plan Formulary |
Freedom Medi-Medi Full (HMO SNP)
|
$22.10 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
n/a | n/a | S | $33.81 |
Browse Plan Formulary |
Freedom Medi-Medi Partial (HMO SNP)
|
$22.10 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | S | $33.81 |
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 |
MediMax (HMO)
|
$22.10 |
$310 |
Call plan for details |
1 |
Preferred Generic |
25% | n/a | P | $31.06 |
Browse Plan Formulary |
Optimum Emerald Full (HMO SNP)
|
$22.10 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
n/a | n/a | S | $33.76 |
Browse Plan Formulary |
Optimum Emerald Partial (HMO SNP)
|
$22.10 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | S | $33.76 |
Browse Plan Formulary |
Simply Care (HMO SNP)
|
$22.10 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | n/a | P | $27.18 |
Browse Plan Formulary |
Simply Comfort (HMO SNP)
|
$22.10 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | n/a | P | $27.18 |
Browse Plan Formulary |
Simply Complete (HMO SNP)
|
$22.10 |
$310* |
Many Generics |
1* |
Preferred Generic |
$0.00 | $0.00 | P | $27.18 |
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 Premier Plan (PPO)
|
$35.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$4.00 | $8.00 | P | $26.72 |
Browse Plan Formulary |