SULFACETAMIDE 10% EYE OINTMENT (3.5 GM ) (NDC: 00574419035)
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 Choice Plan 2 (Regional PPO)
|
$0.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Non-Preferred Generic |
$8.00 | $16.00 | None | $46.92 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $56.93 |
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 | $54.33 |
Browse Plan Formulary |
Amerivantage Specialty + Rx (HMO SNP)
|
$0.00 |
$320 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $120.00 | None | $54.33 |
Browse Plan Formulary |
AvMed Medicare Choice (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$0.00 | $0.00 | None | $50.42 |
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 |
CareDirect (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$0.00 | $0.00 | None | $68.72 |
Browse Plan Formulary |
CareFree PLUS (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$0.00 | $0.00 | None | $68.72 |
Browse Plan Formulary |
CareHeart (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$0.00 | $0.00 | None | $68.72 |
Browse Plan Formulary |
CareOne PLUS (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$0.00 | $0.00 | None | $68.72 |
Browse Plan Formulary |
Coventry Summit Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Non-Preferred Brand |
50% | 50% | None | $47.67 |
Browse Plan Formulary |
Coventry Vista Ideal (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Non-Preferred Brand |
50% | 50% | None | $47.67 |
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 (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$0.00 | $0.00 | None | $68.72 |
Browse Plan Formulary |
Humana Gold Plus - Heart (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$0.00 | $0.00 | None | $68.72 |
Browse Plan Formulary |
Humana Gold Plus H1036-054C (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$0.00 | $0.00 | None | $68.72 |
Browse Plan Formulary |
Humana Gold Plus H1036-237 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $0.00 | None | $70.62 |
Browse Plan Formulary |
Humana Gold Plus H1036-237 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $0.00 | None | $68.72 |
Browse Plan Formulary |
HumanaChoice R5826-074 (Regional PPO)
|
$0.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$15.00 | $0.00 | None | $71.16 |
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 |
Leon Medical Centers Health Plans - Leon Cares (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Generic |
$0.00 | n/a | None | $22.63 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $44.69 |
Browse Plan Formulary |
Preferred Choice Dade (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $44.69 |
Browse Plan Formulary |
Preferred Complete Care (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $44.69 |
Browse Plan Formulary |
Preferred Special Care Miami-Dade (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $44.69 |
Browse Plan Formulary |
Simply Extra (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $56.44 |
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 |
Simply Level (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $56.44 |
Browse Plan Formulary |
Simply More (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $56.44 |
Browse Plan Formulary |
WellCare Dividend (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $58.67 |
Browse Plan Formulary |
WellCare Essential (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $58.83 |
Browse Plan Formulary |
CareNeeds (HMO SNP)
|
$15.00 |
$320* | No additional gap coverage, only the Donut Hole Discount | 2* |
Non-Preferred Generic |
$0.00 | $0.00 | None | $68.72 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-077A (HMO SNP)
|
$15.10 |
$320* | No additional gap coverage, only the Donut Hole Discount | 2* |
Non-Preferred Generic |
$0.00 | $0.00 | None | $68.72 |
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 Select (HMO SNP)
|
$19.90 |
$320* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $58.73 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$20.90 |
$320* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $58.67 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax Plus (HMO-POS SNP)
|
$24.30 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $46.21 |
Browse Plan Formulary |
Preferred Medicare Assist (HMO-POS SNP)
|
$24.40 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $46.21 |
Browse Plan Formulary |
Coventry Summit Maximum (HMO SNP)
|
$24.60 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Non-Preferred Brand |
50% | 50% | None | $46.36 |
Browse Plan Formulary |
WellCare Liberty (HMO SNP)
|
$24.60 |
$320* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $58.67 |
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)
|
$24.80 |
$320* | Yes, but No Gap Coverage for this drug. | 1* |
Generic |
$0.00 | $0.00 | None | $50.42 |
Browse Plan Formulary |
Coventry Vista Maximum (HMO SNP)
|
$25.80 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
50% | 50% | None | $47.60 |
Browse Plan Formulary |
Simply Care (HMO SNP)
|
$25.80 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$5.00 | n/a | None | $56.44 |
Browse Plan Formulary |
Simply Comfort (HMO SNP)
|
$25.80 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$5.00 | n/a | None | $56.44 |
Browse Plan Formulary |
Simply Complete (HMO SNP)
|
$25.80 |
$320* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $56.44 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP (Regional PPO SNP)
|
$25.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $46.92 |
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)
|
$31.60 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $45.11 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$35.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$3.00 | $9.00 | None | $56.93 |
Browse Plan Formulary |
HumanaChoice R5826-005 (Regional PPO)
|
$39.40 |
$100* | Yes, but No Gap Coverage for this drug. | 2* |
Non-Preferred Generic |
$8.00 | $0.00 | None | $71.16 |
Browse Plan Formulary |
HumanaChoice H5415-056 (PPO)
|
$43.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $0.00 | None | $69.26 |
Browse Plan Formulary |
Humana Gold Choice H8145-061 (PFFS)
|
$101.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$15.00 | $0.00 | None | $69.40 |
Browse Plan Formulary |
Aetna Medicare Select Plus Plan (HMO)
|
$139.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$3.00 | $7.50 | None | $56.93 |
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 Select Plus Plan (PPO)
|
$139.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$3.00 | $7.50 | None | $56.94 |
Browse Plan Formulary |