CIPROFLOX-DEXAMETH OTIC SUSPENSION EYE DROPPER [Ciprodex Otic] (7.5 MLS ) (NDC: 00781618667)
2022 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 Medicare Advantage Plan 6 (HMO)
|
$0.00 |
$195 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $187.12 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Walgreens (PPO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $188.16 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Better Health of Ohio, MyCare Ohio (Medicare-Medicaid Plan)
|
$0.00 |
$0 | All Generics, All Brands | 1 |
Tier 1 |
0% | 0% | None | $224.16 |
Browse Plan Formulary |
Aetna Medicare Premier (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $70.40 |
Browse Plan Formulary |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$150* | Yes, but No Gap Coverage for this drug. | 3* |
Preferred Brand |
$47.00 | $141.00 | None | $68.80 |
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 |
Anthem MediBlue + Kroger Access (PPO)
|
$0.00 |
$195 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $181.60 |
Browse Plan Formulary |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $168.00 |
Browse Plan Formulary |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $179.44 |
Browse Plan Formulary |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $172.56 |
Browse Plan Formulary |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $158.80 |
Browse Plan Formulary |
Humana Gold Plus H6622-021 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$97.00 | $281.00 | None | $161.92 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
|
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 H6622-021 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$97.00 | $281.00 | None | $169.52 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5216-285 (PPO)
|
$0.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $167.92 |
Browse Plan Formulary |
HumanaChoice H5525-042 (PPO)
|
$0.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $168.16 |
Browse Plan Formulary |
MediGold Prime Choice (PPO)
|
$0.00 |
$150 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $223.68 |
Browse Plan Formulary |
MediGold Southwest OH Essential Care (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $224.16 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MedMutual Advantage Access (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$8.00 | $15.00 | None | $186.48 |
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 |
MedMutual Advantage Access (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$8.00 | $15.00 | None | $186.80 |
Browse Plan Formulary |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $186.80 |
Browse Plan Formulary |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $184.40 |
Browse Plan Formulary |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $186.48 |
Browse Plan Formulary |
MedMutual Advantage Signature (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$8.00 | $15.00 | None | $187.12 |
Browse Plan Formulary |
MedMutual Advantage Signature (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$8.00 | $15.00 | None | $186.48 |
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 |
MedMutual Advantage Signature (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$8.00 | $15.00 | None | $186.64 |
Browse Plan Formulary |
Molina Dual Options MyCare Ohio (Medicare-Medicaid Plan)
|
$0.00 |
$0 | All Generics, All Brands | 1 |
Tier 1 |
0% | 0% | None | $200.80 |
Browse Plan Formulary |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$12.00 | $24.00 | None | $224.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$16.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $168.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Anthem MediBlue Preferred Plus (HMO)
|
$19.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $167.60 |
Browse Plan Formulary |
HumanaChoice H5216-109 (PPO)
|
$19.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $168.24 |
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 |
AARP Medicare Advantage Plan 2 (HMO)
|
$20.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $187.12 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Plan 2 (HMO)
|
$20.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $182.32 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H6622-055 (HMO)
|
$20.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $169.52 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Anthem MediBlue Extra (HMO)
|
$22.00 |
$480 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $167.68 |
Browse Plan Formulary |
Aetna Medicare Assure 1 (HMO D-SNP)
|
$23.20 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $70.40 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H6622-015 (HMO D-SNP)
|
$27.60 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $168.24 |
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 |
MedMutual Advantage Secure (HMO)
|
$30.00 |
$95* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $186.80 |
Browse Plan Formulary |
MedMutual Advantage Secure (HMO)
|
$30.00 |
$95* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $186.48 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO-POS D-SNP)
|
$33.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | None | $182.56 |
Browse Plan Formulary |
Aetna Medicare Premier Plus 2 (Regional PPO)
|
$33.40 |
$260 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $70.24 |
Browse Plan Formulary |
Anthem MediBlue + Kroger Dual Advantage (HMO D-SNP)
|
$33.50 |
$330 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $181.60 |
Browse Plan Formulary |
Anthem MediBlue Dual Advantage (HMO D-SNP)
|
$33.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $167.68 |
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 |
CareSource Dual Advantage (HMO D-SNP)
|
$33.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
25% | 25% | None | $198.80 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$33.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
33% | 33% | None | $224.00 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete LP1 (HMO D-SNP)
|
$33.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | None | $182.56 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
|
$33.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $183.44 |
Browse Plan Formulary |
Valor Health Plan (HMO I-SNP)
|
$33.50 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $185.12 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO-POS I-SNP)
|
$33.90 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $178.72 |
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 |
MedMutual Advantage Choice (HMO)
|
$40.00 |
$55* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $186.48 |
Browse Plan Formulary |
MedMutual Advantage Choice (HMO)
|
$40.00 |
$55* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $184.40 |
Browse Plan Formulary |
MedMutual Advantage Choice (HMO)
|
$40.00 |
$55* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $186.80 |
Browse Plan Formulary |
Anthem MediBlue Access Basic (Regional PPO)
|
$41.50 |
$200 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $167.68 |
Browse Plan Formulary |
Aetna Medicare Premier Plus 1 (Regional PPO)
|
$44.50 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $70.16 |
Browse Plan Formulary |
CareSource Advantage (HMO)
|
$45.00 |
$100* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $20.00 | None | $198.80 |
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 R5495-002 (Regional PPO)
|
$47.80 |
$480 | No | 4 |
Non-Preferred Drug |
20% | 20% | None | $168.16 |
Browse Plan Formulary |
MediGold True Advantage (HMO)
|
$49.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$75.00 | $150.00 | None | $224.16 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MedMutual Advantage Select (PPO)
|
$50.00 |
$95* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $186.48 |
Browse Plan Formulary |
MedMutual Advantage Select (PPO)
|
$50.00 |
$95* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $184.40 |
Browse Plan Formulary |
MedMutual Advantage Select (PPO)
|
$50.00 |
$95* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $186.80 |
Browse Plan Formulary |
Anthem MediBlue Access (PPO)
|
$56.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $167.76 |
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 |
MediGold Flexible Choice (PPO)
|
$57.00 |
$150 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $223.68 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5216-023 (PPO)
|
$58.00 |
$100 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $169.36 |
Browse Plan Formulary |
MedMutual Advantage Preferred (PPO)
|
$80.00 |
$55* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $186.48 |
Browse Plan Formulary |
MedMutual Advantage Preferred (PPO)
|
$80.00 |
$55* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $184.40 |
Browse Plan Formulary |
MedMutual Advantage Preferred (PPO)
|
$80.00 |
$55* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $186.80 |
Browse Plan Formulary |
Humana Gold Choice H8145-032 (PFFS)
|
$83.00 |
$225 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $171.12 |
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 |
Humana Gold Plus H6622-019 (HMO)
|
$91.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$97.00 | $281.00 | None | $168.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MedMutual Advantage Plus (HMO)
|
$97.00 |
$55* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $184.40 |
Browse Plan Formulary |
MedMutual Advantage Plus (HMO)
|
$97.00 |
$55* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $186.48 |
Browse Plan Formulary |
MedMutual Advantage Plus (HMO)
|
$97.00 |
$55* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $186.80 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 3 (HMO)
|
$111.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $183.28 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Premier 2 (PPO)
|
$118.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $71.36 |
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 |
MediGold Southwest OH Classic Preferred (HMO)
|
$120.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$75.00 | $150.00 | None | $224.16 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MedMutual Advantage Premium (PPO)
|
$136.00 |
$55* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $186.48 |
Browse Plan Formulary |
MedMutual Advantage Premium (PPO)
|
$136.00 |
$55* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $184.40 |
Browse Plan Formulary |
MedMutual Advantage Premium (PPO)
|
$136.00 |
$55* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $10.00 | None | $186.80 |
Browse Plan Formulary |
Aetna Medicare Premier 1 (PPO)
|
$149.00 |
$150* | Yes, but No Gap Coverage for this drug. | 3* |
Preferred Brand |
$47.00 | $141.00 | None | $70.56 |
Browse Plan Formulary |
HumanaChoice H5525-030 (PPO)
|
$151.00 |
$100 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$97.00 | $281.00 | None | $168.00 |
Browse Plan Formulary |