MOXEZA 5.45mg/mL 3 mL in 1 BOTTLE (3 mL in 1 BOTTLE ) (NDC: 00065000603)
2017 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 |
Aetna Better Health Premier Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | None | $167.37 |
Browse Plan Formulary |
AmeriHealth Caritas VIP Care Plus (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | None | $164.96 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | None | $164.11 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | None | $165.10 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | None | $165.08 |
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 |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | None | $165.04 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | None | $164.60 |
Browse Plan Formulary |
HAP Midwest MI Health Link (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Tier 2 |
0% | n/a | None | $171.06 |
Browse Plan Formulary |
Harbor Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | n/a | None | $164.69 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | None | $166.29 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | None | $162.95 |
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 |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | None | $161.85 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | None | $162.18 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | None | $163.34 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | None | $165.11 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$5.10 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | n/a | None | $166.29 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | None | $163.34 |
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 |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | None | $165.11 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | None | $162.95 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | None | $161.85 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | None | $162.18 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$25.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | None | $165.01 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$25.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | None | $163.70 |
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 |
BCN Advantage HMO HealthySaver (HMO)
|
$25.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | None | $164.52 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$25.50 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | None | $165.10 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$25.50 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | None | $164.85 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$25.50 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | None | $164.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$25.50 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | None | $164.85 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$25.50 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | None | $164.30 |
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 |
HAP Midwest Health Plan (HMO SNP)
|
$34.20 |
$370 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | None | $170.60 |
Browse Plan Formulary |
BCN Advantage HMO ConnectedCare (HMO)
|
$58.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | None | $164.52 |
Browse Plan Formulary |
Harbor Medicare Select (HMO)
|
$60.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | n/a | None | $164.69 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$66.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | n/a | None | $164.88 |
Browse Plan Formulary |
McLaren Advantage Sapphire (HMO)
|
$73.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$85.00 | n/a | None | $171.08 |
Browse Plan Formulary |
McLaren Advantage Sapphire (HMO)
|
$73.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$85.00 | n/a | None | $170.60 |
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 Premier Plan (PPO)
|
$75.00 |
$245 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $167.37 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | n/a | None | $164.88 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | n/a | None | $162.12 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | n/a | None | $161.95 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | n/a | None | $162.20 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | n/a | None | $163.59 |
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 |
Medicare Plus Blue PPO Vitality (PPO)
|
$111.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | None | $164.85 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$111.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | None | $164.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$111.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | None | $164.30 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$111.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | None | $165.10 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$111.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | None | $164.85 |
Browse Plan Formulary |
McLaren Advantage Diamond (HMO)
|
$132.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$85.00 | n/a | None | $170.60 |
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 |
McLaren Advantage Diamond (HMO)
|
$132.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$85.00 | n/a | None | $171.08 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$145.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$83.00 | n/a | None | $164.88 |
Browse Plan Formulary |
McLaren Advantage Diamond + (HMO)
|
$160.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$85.00 | n/a | None | $170.60 |
Browse Plan Formulary |
McLaren Advantage Diamond + (HMO)
|
$160.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$85.00 | n/a | None | $171.08 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$166.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | None | $165.08 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$166.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | None | $165.04 |
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 |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$166.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | None | $164.60 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$166.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | None | $164.11 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$166.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | None | $165.10 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$174.00 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | None | $164.85 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$174.00 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | None | $164.85 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$174.00 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | None | $164.60 |
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 |
Medicare Plus Blue PPO Signature (PPO)
|
$174.00 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | None | $164.30 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$174.00 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | None | $165.10 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$201.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$80.00 | n/a | None | $162.20 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$201.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$80.00 | n/a | None | $164.88 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$201.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$80.00 | n/a | None | $163.59 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$201.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$80.00 | n/a | None | $162.12 |
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 |
PriorityMedicare Select (PPO)
|
$201.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$80.00 | n/a | None | $161.95 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$303.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | None | $165.04 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$303.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | None | $164.60 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$303.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | None | $164.11 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$303.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | None | $165.10 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$303.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | None | $165.08 |
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 |
Medicare Plus Blue PPO Assure (PPO)
|
$314.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | None | $164.30 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$314.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | None | $165.10 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$314.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | None | $164.85 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$314.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | None | $164.85 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$314.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | n/a | None | $164.60 |
Browse Plan Formulary |