CLOBETASOL EMOLLNT 0.05% FOAM [Olux-E] (50 grams ) (NDC: 45802063733)
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 |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $312.64 |
Browse Plan Formulary |
BCN Advantage HMO HealthyValue (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $367.22 |
Browse Plan Formulary |
BCN Advantage HMO HealthyValue (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $349.99 |
Browse Plan Formulary |
BCN Advantage HMO HealthyValue (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $363.09 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $344.55 |
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 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $365.32 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $386.25 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $398.27 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $341.28 |
Browse Plan Formulary |
MeridianCare Essential (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $30.00 | None | $119.86 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $342.43 |
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 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $333.11 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $335.13 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $333.16 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $339.60 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $339.60 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $342.43 |
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)
|
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $333.11 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $335.13 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $333.16 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$17.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $319.67 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$17.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $319.84 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$17.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $320.88 |
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)
|
$17.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $320.26 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$17.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $320.07 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$22.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $367.22 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$22.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $349.99 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$22.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $363.09 |
Browse Plan Formulary |
MeridianCare Extra (HMO SNP)
|
$32.90 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | None | $119.86 |
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 |
Aetna Medicare Standard Plan (PPO)
|
$47.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $312.64 |
Browse Plan Formulary |
BCN Advantage HMO ConnectedCare (HMO)
|
$55.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $367.22 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$61.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $342.43 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$78.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $320.26 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$78.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $320.07 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$78.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $319.67 |
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 |
Medicare Plus Blue PPO Vitality (PPO)
|
$78.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $320.88 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$78.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $319.84 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$81.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $339.60 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$81.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $342.43 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$81.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $333.11 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$81.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $335.13 |
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 Merit (PPO)
|
$81.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $333.16 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$87.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:100 /30Days | $312.64 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$102.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $398.27 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$102.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $341.28 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$102.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $344.55 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$102.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $365.32 |
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)
|
$102.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $386.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$130.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $319.84 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$130.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $320.88 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$130.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $320.26 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$130.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $320.07 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$130.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $319.67 |
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 |
PriorityMedicare (HMO-POS)
|
$153.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | None | $342.43 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$170.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | None | $335.13 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$170.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | None | $333.16 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$170.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | None | $339.60 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$170.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | None | $342.43 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$170.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | None | $333.11 |
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 |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$259.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $341.28 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$259.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $344.55 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$259.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $365.32 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$259.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $386.25 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$259.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $398.27 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$263.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $320.07 |
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 |
Medicare Plus Blue PPO Assure (PPO)
|
$263.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $319.67 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$263.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $319.84 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$263.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $320.88 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$263.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $320.26 |
Browse Plan Formulary |