CICLOPIROX 0.77% TOPICAL SUSP (60.000 ML ) (NDC: 45802040046)
2019 Medicare Prescription Drug Plan (MAPD) Information
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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 Plan 1 (HMO)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $55.68 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$195* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | None | $55.62 |
Browse Plan Formulary |
Aetna Medicare Plus Plan (PPO)
|
$0.00 |
$345 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $136.00 | None | $47.57 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$0.00 |
$295 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $136.00 | None | $47.50 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $136.00 | None | $47.53 |
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 |
Amerigroup Medicare-Medicaid Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | 0% | None | $65.85 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $67.36 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $73.09 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $83.57 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $75.82 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $61.54 |
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 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $67.59 |
Browse Plan Formulary |
Amerivantage COPD (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$15.00 | $30.00 | None | $60.16 |
Browse Plan Formulary |
Amerivantage Diabetes (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$15.00 | $30.00 | None | $60.16 |
Browse Plan Formulary |
Amerivantage Heart (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$15.00 | $30.00 | None | $60.16 |
Browse Plan Formulary |
Amerivantage Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | None | $61.14 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Basic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$8.00 | $24.00 | None | $99.25 |
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 |
Cigna-HealthSpring Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $80.00 | None | $59.91 |
Browse Plan Formulary |
Humana Gold Plus H0028-038 (HMO)
|
$0.00 |
$360* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | None | $78.04 |
Browse Plan Formulary |
Humana Gold Plus H0028-042 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $78.03 |
Browse Plan Formulary |
Imperial Insurance Company of Texas Traditional (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $97.18 |
Browse Plan Formulary |
Imperial Insurance Company of Texas Value HMO SNP (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $97.18 |
Browse Plan Formulary |
KelseyCare Advantage Rx (HMO)
|
$0.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$3.00 | n/a | None | $63.63 |
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 |
Memorial Hermann Advantage (HMO)
|
$0.00 |
$300* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | $30.00 | None | $88.86 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | 0% | None | $108.92 |
Browse Plan Formulary |
UnitedHealthcare Connected (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | 0% | None | $55.37 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Choice (Regional PPO SNP)
|
$0.00 |
$415 |
to be determined |
3 |
All Formulary Drugs |
$0.00 | $0.00 | None | $55.88 |
Browse Plan Formulary |
UnitedHealthcare Medicare Silver (Regional PPO SNP)
|
$0.00 |
$364 |
to be determined |
3 |
Preferred Brand |
25% | 25% | None | $55.88 |
Browse Plan Formulary |
WellCare Dividend Prime (HMO)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$30.00 | $60.00 | None | $63.40 |
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 TexanPlus Choice (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $0.00 | None | $63.27 |
Browse Plan Formulary |
WellCare TexanPlus Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $0.00 | None | $63.27 |
Browse Plan Formulary |
WellCare Value (HMO-POS)
|
$0.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | $60.00 | None | $61.70 |
Browse Plan Formulary |
UnitedHealthcare Medicare Gold (Regional PPO SNP)
|
$6.50 |
$295* |
to be determined |
3* |
Preferred Brand |
$47.00 | $131.00 | None | $55.88 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$15.00 |
$245 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $136.00 | None | $47.50 |
Browse Plan Formulary |
HumanaChoice H5216-043 (PPO)
|
$15.00 |
$295* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | None | $79.11 |
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 H5216-043 (PPO)
|
$15.00 |
$295* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | None | $78.48 |
Browse Plan Formulary |
Cigna-HealthSpring TotalCare (HMO SNP)
|
$17.70 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
3 |
All Formulary Drugs |
15% | 15% | None | $59.91 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Choice Plus (PPO)
|
$20.00 |
$415* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$14.00 | $42.00 | None | $99.23 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$23.40 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
3 |
All Formulary Drugs |
15% | 15% | None | $56.11 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H0028-031 (HMO SNP)
|
$23.90 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $78.54 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H0028-033 (HMO SNP)
|
$23.90 |
$365 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $78.04 |
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 |
HumanaChoice R4182-004 (Regional PPO)
|
$23.90 |
$175 |
to be determined |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $78.52 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO SNP)
|
$24.00 |
$415 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $61.54 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO SNP)
|
$24.00 |
$415 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $67.59 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO SNP)
|
$24.00 |
$415 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $67.36 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO SNP)
|
$24.00 |
$415 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $73.09 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO SNP)
|
$24.00 |
$415 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $75.82 |
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 Dual Coordination (HMO SNP)
|
$24.00 |
$415 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $83.57 |
Browse Plan Formulary |
Amerivantage Dual Premier (HMO SNP)
|
$24.00 |
$415 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $61.54 |
Browse Plan Formulary |
Imperial Insurance Company of Texas Dual (HMO SNP) (HMO SNP)
|
$24.00 |
$415 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | 25% | None | $97.18 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$24.00 |
$415 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $108.94 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$24.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
3 |
All Formulary Drugs |
25% | 25% | None | $55.66 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$24.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $61.70 |
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 |
WellCare Liberty (HMO SNP)
|
$24.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $61.70 |
Browse Plan Formulary |
WellCare TexanPlus Star (HMO SNP)
|
$24.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $63.27 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (Regional PPO)
|
$28.50 |
$325 |
to be determined |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $55.88 |
Browse Plan Formulary |
Erickson Advantage Guardian (HMO-POS SNP)
|
$33.10 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$28.00 | $74.00 | None | $57.19 |
Browse Plan Formulary |
HumanaChoice R4182-003 (Regional PPO)
|
$33.70 |
$175 |
to be determined |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $78.52 |
Browse Plan Formulary |
Erickson Advantage Freedom (HMO-POS)
|
$48.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $57.19 |
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 |
KelseyCare Advantage Rx+Choice (HMO-POS)
|
$77.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$3.00 | n/a | None | $63.63 |
Browse Plan Formulary |
HumanaChoice H5216-042 (PPO)
|
$87.00 |
$175* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | None | $78.42 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Choice Premier (PPO)
|
$90.00 |
$415* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$14.00 | $42.00 | None | $99.23 |
Browse Plan Formulary |
Humana Gold Choice H8145-084 (PFFS)
|
$116.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | None | $78.46 |
Browse Plan Formulary |
Aetna Medicare Value Plan (PPO)
|
$150.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $136.00 | None | $47.50 |
Browse Plan Formulary |
Erickson Advantage Champion (HMO-POS SNP)
|
$195.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $57.19 |
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 |
Erickson Advantage Signature with Drugs (HMO-POS)
|
$195.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $57.19 |
Browse Plan Formulary |