Apraclonidine Ophthalmic 5mg/mL 1 BOTTLE, DROPPER per CARTON / 10 mL in 1 BOTTLE, DROPPER (1 BOTTLE, DROPPER in 1 CA ) (NDC: 17478071611)
2015 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 |
$150 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$44.00 | $122.00 | None | $105.30 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$260 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $125.00 | None | $105.30 |
Browse Plan Formulary |
Advantage Care (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$2.00 | $5.00 | None | $143.53 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $135.00 | None | $135.81 |
Browse Plan Formulary |
AgeWell New York FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
0% | 0% | None | $138.68 |
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 |
AlphaCare Renew (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$15.00 | n/a | None | $143.41 |
Browse Plan Formulary |
AlphaCare Signature FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
0% | n/a | None | $143.41 |
Browse Plan Formulary |
Amerivantage Balance + Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$15.00 | $30.00 | None | $151.58 |
Browse Plan Formulary |
Amerivantage Specialty + Rx (HMO SNP)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$20.00 | $40.00 | None | $151.43 |
Browse Plan Formulary |
Amida Care True Life Plus (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$33.00 | $99.00 | None | $151.58 |
Browse Plan Formulary |
CenterLight Healthcare FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
0% | 0% | None | $151.49 |
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 |
EmblemHealth Dual Assurance FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
0% | 0% | None | $150.69 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $150.75 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $149.59 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $151.16 |
Browse Plan Formulary |
Empire Dual Advantage (HMO SNP)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $151.38 |
Browse Plan Formulary |
FIDA Care Complete (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
0% | n/a | None | $143.53 |
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 |
GuildNet Gold Plus FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
0% | 0% | None | $150.69 |
Browse Plan Formulary |
HealthPlus Amerigroup FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
0% | 0% | None | $151.58 |
Browse Plan Formulary |
Humana Gold Plus H3533-017 (HMO)
|
$0.00 |
$320 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $171.78 |
Browse Plan Formulary |
ICS Community Care Plus FIDA MMP (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
0% | 0% | None | $143.41 |
Browse Plan Formulary |
Integra FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
0% | 0% | None | $145.13 |
Browse Plan Formulary |
Liberty Health Advantage Preferred Choice (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $136.62 |
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 |
RiverSpring FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
0% | 0% | None | $72.92 |
Browse Plan Formulary |
SWH Whole Health FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
0% | 0% | None | $150.72 |
Browse Plan Formulary |
Touchstone Health Medicare Freedom (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $136.62 |
Browse Plan Formulary |
Touchstone Health Medicare Power (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $136.62 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (Regional PPO)
|
$0.00 |
$225 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $125.00 | None | $105.51 |
Browse Plan Formulary |
VillageCareMAX Full Advantage FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
0% | 0% | None | $143.41 |
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 FIDA Complete (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Tier 1 |
0% | 0% | None | $132.23 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Enhanced (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$9.00 | $27.00 | None | $132.23 |
Browse Plan Formulary |
Access Medicare Gold (HMO)
|
$12.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$8.00 | $12.00 | None | $145.39 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$23.00 |
$257 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$22.00 | $44.00 | None | $152.32 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$23.00 |
$257 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$22.00 | $44.00 | None | $152.72 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$23.00 |
$257 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$22.00 | $44.00 | None | $152.56 |
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)
|
$23.00 |
$257 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$22.00 | $44.00 | None | $145.41 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H3533-004 (HMO SNP)
|
$28.70 |
$125 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $172.28 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
|
$29.00 |
$230 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $125.00 | None | $105.30 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$30.30 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $102.77 |
Browse Plan Formulary |
LiveWell (HMO)
|
$32.90 |
$250 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $138.68 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Classic (HMO)
|
$34.10 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $132.23 |
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 |
AlphaCare Resilience (HMO SNP)
|
$36.10 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | None | $143.41 |
Browse Plan Formulary |
AlphaCare Total (HMO SNP)
|
$36.20 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | n/a | None | $143.41 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Preferred (HMO SNP)
|
$36.30 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $132.23 |
Browse Plan Formulary |
Access Medicare Pearl (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $145.39 |
Browse Plan Formulary |
Access Medicare Platinum (HMO)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $145.39 |
Browse Plan Formulary |
Amida Care Live Life Advantage (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
25% | 25% | None | $151.58 |
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 |
Amida Care True Life Advantage (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $151.58 |
Browse Plan Formulary |
BeWell (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $138.68 |
Browse Plan Formulary |
CareWell (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $138.68 |
Browse Plan Formulary |
CenterLight Healthcare Direct Complete Plan (HMO SNP)
|
$36.90 |
$320* | No additional gap coverage, only the Donut Hole Discount | 2* |
Non-Preferred Generic |
$7.25 | $21.75 | None | $151.53 |
Browse Plan Formulary |
EmblemHealth Dual Eligible (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$9.00 | $27.00 | None | $150.69 |
Browse Plan Formulary |
EmblemHealth Dual Eligible (PPO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$9.00 | $27.00 | None | $150.69 |
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 |
EmblemHealth MLTC PLUS (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$9.00 | $27.00 | None | $150.69 |
Browse Plan Formulary |
FeelWell (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $138.68 |
Browse Plan Formulary |
GuildNet Gold (HMO-POS SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $150.83 |
Browse Plan Formulary |
Liberty Health Advantage Dual Power (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $136.62 |
Browse Plan Formulary |
Senior Whole Health of New York NHC (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $151.56 |
Browse Plan Formulary |
Touchstone Health Medicare Total (HMO)
|
$36.90 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$7.00 | $17.50 | None | $136.62 |
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 (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
$0.00 | $0.00 | None | $106.13 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Maximum (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $132.23 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $132.23 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
|
$49.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $149.59 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
|
$49.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $150.75 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
|
$49.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $151.16 |
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 |
EmblemHealth Advantage (PPO)
|
$96.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $152.35 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$97.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $135.00 | None | $135.81 |
Browse Plan Formulary |
Aetna Medicare Select Plus Plan (PPO)
|
$139.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $135.84 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$233.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $150.75 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$233.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $149.59 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$233.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $151.16 |
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 |
HumanaChoice H5970-013 (PPO)
|
$323.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $171.78 |
Browse Plan Formulary |