LIDOCAINE 5% OINTMENT (1.25 OZ TUBE) (NDC: 00168020437)
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 (HMO)
|
$0.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $75.00 | None | $205.96 |
Browse Plan Formulary |
Advantra (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None | $94.33 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$6.00 | $18.00 | None | $96.24 |
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 | $87.23 |
Browse Plan Formulary |
Amerigroup Medicare-Medicaid Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | None | $241.08 |
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 + Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $236.86 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $247.10 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $247.16 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $245.81 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $239.53 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $246.05 |
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 Select + Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $246.12 |
Browse Plan Formulary |
Amerivantage Specialty + Rx (HMO SNP)
|
$0.00 |
$320 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | None | $241.36 |
Browse Plan Formulary |
Care Improvement Plus Dual Advantage (Regional PPO SNP)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | None | $207.81 |
Browse Plan Formulary |
Care Improvement Plus Gold Rx (PPO SNP)
|
$0.00 |
$315 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $207.93 |
Browse Plan Formulary |
Care Improvement Plus Gold Rx (Regional PPO SNP)
|
$0.00 |
$315 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $207.81 |
Browse Plan Formulary |
Care Improvement Plus Silver Rx (Regional PPO SNP)
|
$0.00 |
$307 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | 25% | None | $207.81 |
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 |
Humana Gold Plus - Diabetes and Heart (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $249.62 |
Browse Plan Formulary |
Humana Gold Plus H4510-015 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $249.62 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | 0% | None | $226.61 |
Browse Plan Formulary |
Superior HealthPlan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | 0% | None | $234.09 |
Browse Plan Formulary |
UnitedHealthcare Chronic Complete (HMO SNP)
|
$0.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $75.00 | None | $205.96 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $246.20 |
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 Value (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $246.20 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$9.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $205.96 |
Browse Plan Formulary |
HumanaChoice R5826-091 (Regional PPO)
|
$15.00 |
$320 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $249.62 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$19.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | None | $96.24 |
Browse Plan Formulary |
Care Improvement Plus Medicare Advantage (PPO)
|
$19.00 |
$315 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $207.93 |
Browse Plan Formulary |
Care Improvement Plus Medicare Advantage (Regional PPO)
|
$19.00 |
$315 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $207.81 |
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 |
Cigna-HealthSpring TotalCare (HMO SNP)
|
$20.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $117.29 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$21.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $100.00 | None | $246.03 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H4510-024 (HMO SNP)
|
$25.70 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $249.62 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$27.30 |
$320* |
Yes, but No Gap Coverage for this drug. |
1* |
Generic |
$0.00 | $0.00 | None | $226.62 |
Browse Plan Formulary |
Superior HealthPlan Advantage (HMO SNP)
|
$27.30 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Generic |
$0.00 | $0.00 | None | $234.00 |
Browse Plan Formulary |
Cigna-HealthSpring Preferred (HMO)
|
$28.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$8.00 | $24.00 | None | $117.38 |
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 |
HumanaChoice R5826-012 (Regional PPO)
|
$34.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $249.62 |
Browse Plan Formulary |
Advantra (PPO)
|
$41.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $87.79 |
Browse Plan Formulary |
HumanaChoice H6609-108 (PPO)
|
$66.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $249.62 |
Browse Plan Formulary |
Aetna Medicare Value Plan (PPO)
|
$68.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$9.00 | $27.00 | None | $96.24 |
Browse Plan Formulary |
Humana Gold Choice H8145-084 (PFFS)
|
$89.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $249.62 |
Browse Plan Formulary |
Aetna Medicare Select Plus Plan (PPO)
|
$139.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$3.00 | $7.50 | None | $99.83 |
Browse Plan Formulary |