LUMIGAN 0.1mg/mL 1 BOTTLE, DROPPER per CARTON / 5 mL in 1 BOTTLE, DROPPER (1 BOTTLE, DROPPER in 1 CA ) (NDC: 00023320505)
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)
![Email Prescription and/or Health Benefit details for AARP MedicareComplete SecureHorizons (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $75.00 | None | $275.83 |
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Advantra (HMO)
![Email Prescription and/or Health Benefit details for Advantra (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | None | $280.20 |
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Aetna Medicare Premier Plan (HMO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Premier Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | None | $279.38 |
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Aetna Medicare Prime Plan (HMO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Prime Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | None | $279.38 |
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Amerigroup Medicare-Medicaid Plan (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for Amerigroup Medicare-Medicaid Plan (Medicare-Medicaid Plan)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | None | $278.07 |
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)
![Email Prescription and/or Health Benefit details for Amerivantage Classic + Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $277.60 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
![Email Prescription and/or Health Benefit details for Amerivantage Classic + Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $278.83 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
![Email Prescription and/or Health Benefit details for Amerivantage Classic + Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $277.63 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
![Email Prescription and/or Health Benefit details for Amerivantage Classic + Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $278.12 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
![Email Prescription and/or Health Benefit details for Amerivantage Classic + Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $277.29 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
![Email Prescription and/or Health Benefit details for Amerivantage Classic + Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $278.86 |
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 |
Amerivantage Classic Select + Rx (HMO)
![Email Prescription and/or Health Benefit details for Amerivantage Classic Select + Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $278.97 |
Browse Plan Formulary |
Amerivantage Specialty + Rx (HMO SNP)
![Email Prescription and/or Health Benefit details for Amerivantage Specialty + Rx (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$320 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $135.00 | None | $277.94 |
Browse Plan Formulary |
Care Improvement Plus Dual Advantage (Regional PPO SNP)
![Email Prescription and/or Health Benefit details for Care Improvement Plus Dual Advantage (Regional PPO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | None | $275.71 |
Browse Plan Formulary |
Care Improvement Plus Gold Rx (PPO SNP)
![Email Prescription and/or Health Benefit details for Care Improvement Plus Gold Rx (PPO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$315 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $275.62 |
Browse Plan Formulary |
Care Improvement Plus Gold Rx (Regional PPO SNP)
![Email Prescription and/or Health Benefit details for Care Improvement Plus Gold Rx (Regional PPO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$315 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $275.71 |
Browse Plan Formulary |
Care Improvement Plus Silver Rx (Regional PPO SNP)
![Email Prescription and/or Health Benefit details for Care Improvement Plus Silver Rx (Regional PPO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$307 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | 25% | None | $275.71 |
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)
![Email Prescription and/or Health Benefit details for Humana Gold Plus - Diabetes and Heart (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$43.00 | $119.00 | Q:3 /25Days | $276.84 |
Browse Plan Formulary |
Humana Gold Plus H4510-015 (HMO)
![Email Prescription and/or Health Benefit details for Humana Gold Plus H4510-015 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$43.00 | $119.00 | Q:3 /25Days | $276.78 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for Molina Dual Options (Medicare-Medicaid Plan)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | None | $277.70 |
Browse Plan Formulary |
Superior HealthPlan (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for Superior HealthPlan (Medicare-Medicaid Plan)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | None | $283.85 |
Browse Plan Formulary |
UnitedHealthcare Chronic Complete (HMO SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Chronic Complete (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $75.00 | None | $275.83 |
Browse Plan Formulary |
WellCare Dividend (HMO)
![Email Prescription and/or Health Benefit details for WellCare Dividend (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$30.00 | $75.00 | None | $283.87 |
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)
![Email Prescription and/or Health Benefit details for WellCare Value (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$30.00 | $75.00 | None | $283.87 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Dual Complete (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$9.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $275.83 |
Browse Plan Formulary |
HumanaChoice R5826-091 (Regional PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice R5826-091 (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$15.00 |
$320* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$45.00 | $125.00 | Q:3 /25Days | $276.48 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Choice Plan (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$19.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | None | $279.38 |
Browse Plan Formulary |
Care Improvement Plus Medicare Advantage (PPO)
![Email Prescription and/or Health Benefit details for Care Improvement Plus Medicare Advantage (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$19.00 |
$315 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $275.62 |
Browse Plan Formulary |
Care Improvement Plus Medicare Advantage (Regional PPO)
![Email Prescription and/or Health Benefit details for Care Improvement Plus Medicare Advantage (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$19.00 |
$315 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $275.71 |
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)
![Email Prescription and/or Health Benefit details for Cigna-HealthSpring TotalCare (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$20.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:5 /30Days | $277.51 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
![Email Prescription and/or Health Benefit details for WellCare Access (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$21.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $100.00 | None | $283.91 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H4510-024 (HMO SNP)
![Email Prescription and/or Health Benefit details for Humana Gold Plus SNP-DE H4510-024 (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$25.70 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:3 /25Days | $276.45 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
![Email Prescription and/or Health Benefit details for Molina Medicare Options Plus (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$27.30 |
$320 |
Yes, but No Gap Coverage for this drug. |
2 |
Preferred Brand |
$45.00 | $135.00 | None | $277.71 |
Browse Plan Formulary |
Superior HealthPlan Advantage (HMO SNP)
![Email Prescription and/or Health Benefit details for Superior HealthPlan Advantage (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$27.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$45.00 | $45.00 | None | $283.95 |
Browse Plan Formulary |
Cigna-HealthSpring Preferred (HMO)
![Email Prescription and/or Health Benefit details for Cigna-HealthSpring Preferred (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$28.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35.00 | $105.00 | Q:5 /30Days | $277.51 |
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)
![Email Prescription and/or Health Benefit details for HumanaChoice R5826-012 (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$34.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:3 /25Days | $276.48 |
Browse Plan Formulary |
Advantra (PPO)
![Email Prescription and/or Health Benefit details for Advantra (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$41.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | None | $280.17 |
Browse Plan Formulary |
HumanaChoice H6609-108 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice H6609-108 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$66.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:3 /25Days | $276.55 |
Browse Plan Formulary |
Aetna Medicare Value Plan (PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Value Plan (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$68.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $135.00 | None | $279.38 |
Browse Plan Formulary |
Humana Gold Choice H8145-084 (PFFS)
![Email Prescription and/or Health Benefit details for Humana Gold Choice H8145-084 (PFFS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$89.00 |
$200* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$45.00 | $125.00 | Q:3 /25Days | $276.60 |
Browse Plan Formulary |
Aetna Medicare Select Plus Plan (PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Select Plus Plan (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$139.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $112.50 | None | $279.38 |
Browse Plan Formulary |