BESIVANCE BESIFLOACIN OPTHALMIC SUSPENSION 0.6% 5 ML BOTDR (5 ML BOTDR) (NDC: 24208044605)
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 | $136.18 |
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 | $136.18 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
50% | 50% | None | $138.15 |
Browse Plan Formulary |
Affinity Medicare Passport Essentials (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $112.50 | None | $137.91 |
Browse Plan Formulary |
Fidelis Fully Integrated Dual Advantage (FIDA) (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | n/a | None | $137.38 |
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 Medicare $0 Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $137.39 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $113.00 | None | $137.38 |
Browse Plan Formulary |
Healthfirst AbsoluteCare FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | None | $137.38 |
Browse Plan Formulary |
Humana Gold Plus H3533-016 (HMO)
|
$0.00 |
$320* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$45.00 | $125.00 | None | $136.16 |
Browse Plan Formulary |
MetroPlus FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | None | $137.94 |
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 | $136.26 |
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 Advocate Complete FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
0% | 0% | None | $141.41 |
Browse Plan Formulary |
WellCare Choice (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$84.00 | $210.00 | None | $141.26 |
Browse Plan Formulary |
Fidelis Long Term Care Advantage (HMO SNP)
|
$3.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | None | $137.38 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H3533-018 (HMO SNP)
|
$28.70 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $136.16 |
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 | $136.18 |
Browse Plan Formulary |
WellCare Rx (HMO)
|
$30.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None | $141.26 |
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 Nursing Home Plan (HMO SNP)
|
$30.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | None | $136.19 |
Browse Plan Formulary |
Fidelis Dual Advantage (HMO SNP)
|
$33.10 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $137.39 |
Browse Plan Formulary |
Healthfirst Increased Benefits Plan (HMO)
|
$34.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $137.38 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO SNP)
|
$35.40 |
$320 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $137.39 |
Browse Plan Formulary |
Healthfirst AssuredCare (HMO SNP)
|
$36.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $137.38 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO SNP)
|
$36.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $137.38 |
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 |
Healthfirst Life Improvement Plan (HMO SNP)
|
$36.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $137.38 |
Browse Plan Formulary |
Affinity Medicare Solutions (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | None | $137.91 |
Browse Plan Formulary |
Affinity Medicare Ultimate (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | None | $137.91 |
Browse Plan Formulary |
Amida Care Live Life Advantage (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | 25% | None | $136.92 |
Browse Plan Formulary |
Amida Care True Life Advantage (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $136.92 |
Browse Plan Formulary |
ArchCare Advantage (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $139.23 |
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 |
Fidelis Medicaid Advantage Plus (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $137.38 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
|
$36.90 |
$240 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35.00 | $70.00 | None | $137.39 |
Browse Plan Formulary |
MetroPlus Advantage Plan (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $137.94 |
Browse Plan Formulary |
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 | $136.20 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None | $141.41 |
Browse Plan Formulary |
Affinity Medicare Passport Select (HMO)
|
$46.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $105.00 | None | $137.91 |
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 |
Aetna Medicare Value Plan (HMO)
|
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
50% | 50% | None | $138.15 |
Browse Plan Formulary |
MetroPlus Platinum (HMO)
|
$101.10 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $137.94 |
Browse Plan Formulary |
MetroPlus Select Plan (HMO SNP)
|
$123.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $137.94 |
Browse Plan Formulary |
Affinity Medicare Passport Elite (HMO)
|
$126.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | None | $137.91 |
Browse Plan Formulary |
MetroPlus Medicare Partnership in Care Plan (HMO SNP)
|
$244.20 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $137.94 |
Browse Plan Formulary |