SULFACETAMIDE 10% EYE OINTMENT (3.5 GM ) (NDC: 00574419035)
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 |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$18.00 | n/a | None | $50.05 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$18.00 | n/a | None | $50.05 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$18.00 | n/a | None | $50.05 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$18.00 | n/a | None | $50.05 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$18.00 | n/a | None | $50.05 |
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 |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | None | $46.67 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | None | $51.28 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | None | $43.45 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | None | $47.14 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | None | $50.25 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | None | $50.25 |
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 |
2 |
Tier 2 |
25% | n/a | None | $46.67 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | None | $51.28 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | None | $43.45 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | None | $47.14 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$25.00 |
$100* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$20.00 | n/a | None | $50.05 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$25.00 |
$100* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$20.00 | n/a | None | $50.05 |
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 |
BCN Advantage HMO HealthySaver (HMO)
|
$25.00 |
$100* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$20.00 | n/a | None | $50.05 |
Browse Plan Formulary |
HumanaChoice R5826-006 (Regional PPO)
|
$25.50 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | 25% | None | $62.63 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$25.50 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | None | $50.05 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$25.50 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | None | $50.05 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$25.50 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | None | $50.05 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$25.50 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | None | $50.05 |
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 |
Medicare Plus Blue PPO Essential (PPO)
|
$25.50 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | None | $50.05 |
Browse Plan Formulary |
HAP Midwest Health Plan (HMO SNP)
|
$34.20 |
$370 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
25% | n/a | None | $51.54 |
Browse Plan Formulary |
BCN Advantage HMO ConnectedCare (HMO)
|
$58.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | n/a | None | $50.05 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$66.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | n/a | None | $51.87 |
Browse Plan Formulary |
Humana Gold Plus H8908-001 (HMO)
|
$73.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $61.15 |
Browse Plan Formulary |
McLaren Advantage Sapphire (HMO)
|
$73.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$5.00 | n/a | None | $51.75 |
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 Sapphire (HMO)
|
$73.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$5.00 | n/a | None | $50.58 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | None | $52.60 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | None | $51.87 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | None | $43.43 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | None | $53.26 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | None | $52.73 |
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 |
2 |
Tier 2 |
25% | n/a | None | $50.05 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$111.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | None | $50.05 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$111.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | None | $50.05 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$111.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | None | $50.05 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$111.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | None | $50.05 |
Browse Plan Formulary |
McLaren Advantage Diamond (HMO)
|
$132.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$5.00 | n/a | None | $50.58 |
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 |
1 |
Generic |
$5.00 | n/a | None | $51.75 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$145.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | n/a | None | $51.87 |
Browse Plan Formulary |
McLaren Advantage Diamond + (HMO)
|
$160.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$5.00 | n/a | None | $50.58 |
Browse Plan Formulary |
McLaren Advantage Diamond + (HMO)
|
$160.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$5.00 | n/a | None | $51.75 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$166.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | n/a | None | $50.05 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$166.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | n/a | None | $50.05 |
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 |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$166.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | n/a | None | $50.05 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$166.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | n/a | None | $50.05 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$166.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | n/a | None | $50.05 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$174.00 |
$105* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | n/a | None | $50.05 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$174.00 |
$105* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | n/a | None | $50.05 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$174.00 |
$105* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | n/a | None | $50.05 |
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 |
Medicare Plus Blue PPO Signature (PPO)
|
$174.00 |
$105* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | n/a | None | $50.05 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$174.00 |
$105* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | n/a | None | $50.05 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$201.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | n/a | None | $53.26 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$201.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | n/a | None | $52.73 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$201.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | n/a | None | $52.60 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$201.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | n/a | None | $51.87 |
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 |
PriorityMedicare Select (PPO)
|
$201.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | n/a | None | $43.43 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$303.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | n/a | None | $50.05 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$303.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | n/a | None | $50.05 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$303.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | n/a | None | $50.05 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$303.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | n/a | None | $50.05 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$303.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | n/a | None | $50.05 |
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 |
Medicare Plus Blue PPO Assure (PPO)
|
$314.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$14.00 | n/a | None | $50.05 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$314.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$14.00 | n/a | None | $50.05 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$314.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$14.00 | n/a | None | $50.05 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$314.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$14.00 | n/a | None | $50.05 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$314.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$14.00 | n/a | None | $50.05 |
Browse Plan Formulary |