AK-CON 0.1% EYE DROPS (15 ML BOTDR) (NDC: 17478021612)
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 SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None | $5.09 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None | $5.09 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.00 | $14.00 | None | $5.09 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.00 | $14.00 | None | $5.09 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | None | $7.03 |
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 Prime Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | None | $7.03 |
Browse Plan Formulary |
Anthem Select Advantage (HMO)
|
$0.00 |
$150* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$5.00 | $10.00 | None | $6.49 |
Browse Plan Formulary |
Anthem Select Advantage (HMO)
|
$0.00 |
$150* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$5.00 | $10.00 | None | $6.49 |
Browse Plan Formulary |
Blue Cross Senior Secure Plan I (HMO)
|
$0.00 |
$50* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$5.00 | $10.00 | None | $6.48 |
Browse Plan Formulary |
Blue Cross Senior Secure Plan I (HMO)
|
$0.00 |
$50* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$5.00 | $10.00 | None | $6.48 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None | $5.79 |
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 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None | $5.79 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$3.00 | $6.00 | None | $5.79 |
Browse Plan Formulary |
CareMore Breathe (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.50 | $18.75 | None | $7.00 |
Browse Plan Formulary |
CareMore Breathe (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.50 | $18.75 | None | $7.00 |
Browse Plan Formulary |
CareMore Cal MediConnect Medicare-Medicaid Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Brand Drugs |
0% | 0% | None | $7.00 |
Browse Plan Formulary |
CareMore Cal MediConnect Medicare-Medicaid Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Brand Drugs |
0% | 0% | None | $7.00 |
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 |
CareMore Connect (HMO SNP)
|
$0.00 |
$320* |
Yes, but No Gap Coverage for this drug. |
2* |
Non-Preferred Generic |
$0.00 | $0.00 | None | $7.00 |
Browse Plan Formulary |
CareMore Connect (HMO SNP)
|
$0.00 |
$320* |
Yes, but No Gap Coverage for this drug. |
2* |
Non-Preferred Generic |
$0.00 | $0.00 | None | $7.00 |
Browse Plan Formulary |
CareMore ESRD (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.50 | $18.75 | None | $7.00 |
Browse Plan Formulary |
CareMore ESRD (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.50 | $18.75 | None | $7.00 |
Browse Plan Formulary |
CareMore Heart (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.50 | $18.75 | None | $7.00 |
Browse Plan Formulary |
CareMore Heart (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.50 | $18.75 | None | $7.00 |
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 |
CareMore Reliance (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.50 | $18.75 | None | $7.00 |
Browse Plan Formulary |
CareMore Reliance (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.50 | $18.75 | None | $7.00 |
Browse Plan Formulary |
CareMore StartSmart Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$12.50 | $31.25 | None | $7.00 |
Browse Plan Formulary |
CareMore StartSmart Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$12.50 | $31.25 | None | $7.00 |
Browse Plan Formulary |
CareMore Touch (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.50 | $18.75 | None | $7.00 |
Browse Plan Formulary |
CareMore Touch (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.50 | $18.75 | None | $7.00 |
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 |
CareMore Value Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.50 | $18.75 | None | $7.00 |
Browse Plan Formulary |
CareMore Value Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.50 | $18.75 | None | $7.00 |
Browse Plan Formulary |
Central Health Focus Plan (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None | $7.00 |
Browse Plan Formulary |
Central Health Focus Plan (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None | $7.00 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO SNP)
|
$0.00 |
$320* |
Yes, but No Gap Coverage for this drug. |
2* |
Non-Preferred Generic |
$0.00 | $0.00 | None | $7.00 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None | $7.00 |
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 |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None | $7.00 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $6.55 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $6.55 |
Browse Plan Formulary |
Easy Choice Freedom Plan (HMO SNP)
|
$0.00 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.55 |
Browse Plan Formulary |
Golden State Medicare Health Plan, Golden (HMO)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
$5.00 | $10.00 | None | $5.84 |
Browse Plan Formulary |
Golden State Medicare Health Plan, Golden (HMO)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
$5.00 | $10.00 | None | $5.90 |
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 Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $7.10 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $7.10 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $7.10 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $7.10 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$3.00 | $6.00 | None | $7.36 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$3.00 | $6.00 | None | $7.36 |
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 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$3.00 | $6.00 | None | $7.36 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$3.00 | $6.00 | None | $7.36 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$0.00 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $7.10 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$0.00 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $7.10 |
Browse Plan Formulary |
Humana Gold Plus H0108-011 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $6.94 |
Browse Plan Formulary |
Inter Valley Health Plan Service To Seniors (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$5.00 | $10.00 | None | $7.00 |
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 |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$12.00 | $24.00 | None | $10.27 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$12.00 | $24.00 | None | $10.27 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $10.30 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $10.30 |
Browse Plan Formulary |
L.A Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Brand Drugs |
0% | 0% | None | $6.69 |
Browse Plan Formulary |
L.A Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Brand Drugs |
0% | 0% | None | $6.69 |
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 |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic Drugs |
0% | 0% | None | $6.37 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic Drugs |
0% | 0% | None | $6.37 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$0.00 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Generic |
$0.00 | $0.00 | None | $6.37 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None | $10.27 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$14.80 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$8.00 | $24.00 | None | $7.03 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$15.30 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None | $10.27 |
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 |
Molina Medicare Options Plus (HMO SNP)
|
$21.90 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Generic |
$0.00 | $0.00 | None | $6.37 |
Browse Plan Formulary |
Humana Gold Plus H0108-050 (HMO)
|
$22.90 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.95 |
Browse Plan Formulary |
Easy Choice Freedom Plan (HMO SNP)
|
$23.80 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.55 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$23.80 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.55 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$23.80 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $6.55 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$28.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$8.00 | $24.00 | None | $7.03 |
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 H0108-047 (HMO)
|
$28.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $6.94 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 3 (HMO)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $5.08 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 3 (HMO)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $5.08 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO SNP)
|
$28.80 |
$320* |
Yes, but No Gap Coverage for this drug. |
2* |
Non-Preferred Generic |
$0.00 | $0.00 | None | $7.00 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$28.80 |
$320* |
Yes, but No Gap Coverage for this drug. |
2* |
Non-Preferred Generic |
$0.00 | $0.00 | None | $7.00 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$28.80 |
$320* |
Yes, but No Gap Coverage for this drug. |
2* |
Non-Preferred Generic |
$0.00 | $0.00 | None | $7.00 |
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 |
Health Net Seniority Plus Amber I (HMO SNP)
|
$28.80 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $7.10 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$28.80 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $7.10 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$28.80 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $7.10 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$28.80 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $7.10 |
Browse Plan Formulary |
Health Net Seniority Plus Complete (HMO)
|
$66.30 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$5.00 | $10.00 | None | $7.10 |
Browse Plan Formulary |
Health Net Seniority Plus Complete (HMO)
|
$176.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$5.00 | $10.00 | None | $7.10 |
Browse Plan Formulary |