LIDOCAINE 2% VISCOUS SOLUTION (100.000 ML ) (NDC: 50383077504)
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 Choice (PPO)
|
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$10.00 | $0.00 | None | $9.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Choice Plan 2 (Regional PPO)
|
$0.00 |
$395* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$14.00 | $28.00 | None | $9.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Advantage Care by Ultimate (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
1 |
Generic |
$0.00 | $0.00 | None | $9.00 |
Browse Plan Formulary select insulin pay $10 copay but not this drug |
Advantage Care COPD by Ultimate (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
1 |
Generic |
$0.00 | $0.00 | None | $9.00 |
Browse Plan Formulary select insulin pay $10 copay but not this drug |
Aetna Medicare Premier (PPO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $10.00 |
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 Plus (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $10.00 |
Browse Plan Formulary |
Aetna Medicare Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None | $11.00 |
Browse Plan Formulary |
Align Connect (HMO C-SNP)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $45.00 | None | $13.00 |
Browse Plan Formulary |
BlueMedicare Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $30.00 | None | $10.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BlueMedicare Premier (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $10.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BlueMedicare Value (PPO)
|
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$8.00 | $24.00 | None | $10.00 |
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 |
Bright Advantage Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics |
2 |
Generic |
$9.00 | $18.00 | None | $9.00 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Bright Advantage Health Dollars Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $10.00 | None | $9.00 |
Browse Plan Formulary |
Bright Advantage Part B Savings Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$9.00 | $18.00 | None | $9.00 |
Browse Plan Formulary |
Bright Advantage Part B Savings Plan (PPO)
|
$0.00 |
$110 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | None | $9.00 |
Browse Plan Formulary |
CareBreeze (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
2 |
Generic |
$5.00 | $0.00 | None | $9.00 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
CareComplete (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
2 |
Generic |
$5.00 | $0.00 | None | $9.00 |
Browse Plan Formulary select insulin pay $20-$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 |
CareFree (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $0.00 | None | $9.00 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
CareFree (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $0.00 | None | $9.00 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
CareOne PLATINUM (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $9.00 |
Browse Plan Formulary select insulin pay $0-$30 copay but not this drug |
CareOne PLUS (HMO-POS)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $9.00 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $12.00 |
Browse Plan Formulary |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $12.00 |
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 True Choice Medicare (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$2.00 | $0.00 | None | $12.00 |
Browse Plan Formulary |
Devoted Health Core (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | None | $8.00 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Devoted Health Essentials (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$5.00 | $12.50 | None | $8.00 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Freedom Platinum Plan Rx (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $9.00 |
Browse Plan Formulary |
Freedom Platinum Rewards Plan Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $9.00 |
Browse Plan Formulary |
Freedom VIP Care (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Some Brands |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $9.00 |
Browse Plan Formulary select insulin pay $0 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 |
Freedom VIP Savings (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Some Brands |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $9.00 |
Browse Plan Formulary select insulin pay $0-$10 copay but not this drug |
Freedom VIP Savings COPD (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $9.00 |
Browse Plan Formulary |
Humana Community (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $9.00 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
2 |
Generic |
$7.00 | $0.00 | None | $9.00 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
Humana Gold Plus H1036-146 (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $9.00 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
Humana Gold Plus H1036-269 (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$15.00 | $0.00 | None | $9.00 |
Browse Plan Formulary select insulin pay $20-$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 |
HumanaChoice Florida H5216-074 (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $0.00 | None | $9.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Optimum Diamond Rewards (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $9.00 |
Browse Plan Formulary |
Optimum Diamond Rewards COPD (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $9.00 |
Browse Plan Formulary |
Optimum Gold Rewards Plan (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $9.00 |
Browse Plan Formulary |
Premier by Ultimate (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Generic |
$0.00 | $0.00 | None | $9.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Premier Plus by Ultimate (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Generic |
$0.00 | $0.00 | None | $9.00 |
Browse Plan Formulary select insulin pay $30 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 |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150* |
Some Generics |
2* |
Generic |
$0.00 | $0.00 | None | $9.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150* |
Some Generics |
2* |
Generic |
$0.00 | $0.00 | None | $9.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150* |
Some Generics |
2* |
Generic |
$0.00 | $0.00 | None | $9.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150* |
Some Generics |
2* |
Generic |
$0.00 | $0.00 | None | $9.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare The Villages Medicare Advantage (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$7.00 | $0.00 | None | $9.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Giveback (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | None | $4.00 |
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 No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | None | $4.00 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
|
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$0.00 | $0.00 | None | $4.00 |
Browse Plan Formulary |
HumanaChoice R5826-074 (Regional PPO)
|
$0.50 |
$395* |
No |
2* |
Generic |
$20.00 | $0.00 | None | $9.00 |
Browse Plan Formulary |
CareNeeds PLUS (HMO D-SNP)
|
$14.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$4.00 | $0.00 | None | $9.00 |
Browse Plan Formulary |
Humana Fully Integrated H1036-283 (HMO D-SNP)
|
$15.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$3.00 | $0.00 | None | $9.00 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-213 (HMO D-SNP)
|
$22.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $0.00 | None | $9.00 |
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 |
Align Thrive (HMO I-SNP)
|
$22.90 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $45.00 | None | $13.00 |
Browse Plan Formulary |
Cigna Primary Medicare (HMO)
|
$23.60 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$1.00 | $0.00 | None | $12.00 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP (Regional PPO D-SNP)
|
$31.50 |
$480 |
No |
2 |
Tier 2 |
15% | 15% | None | $9.00 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
|
$32.30 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$0.00 | $0.00 | None | $7.00 |
Browse Plan Formulary |
Advantage Plus by Ultimate (Full) (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $9.00 |
Browse Plan Formulary |
Advantage Plus by Ultimate (Partial) (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $9.00 |
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 |
BlueMedicare Complete (HMO D-SNP)
|
$34.30 |
$480* |
Some Generics, Few Brands |
2* |
Generic |
$0.00 | $0.00 | None | $10.00 |
Browse Plan Formulary |
Bright Advantage Embrace Assist Plan (HMO C-SNP)
|
$34.30 |
$480 |
Some Generics |
2 |
Generic |
25% | 25% | None | $9.00 |
Browse Plan Formulary |
Bright Advantage Embrace Choice Plan (HMO C-SNP)
|
$34.30 |
$480 |
Some Generics |
2 |
Generic |
25% | 25% | None | $9.00 |
Browse Plan Formulary |
Devoted Health Dual (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | None | $8.00 |
Browse Plan Formulary |
Devoted Health Prime (HMO)
|
$34.30 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | None | $8.00 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Freedom Medi-Medi Full (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$10.00 | $30.00 | None | $9.00 |
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 |
Freedom Medi-Medi Partial (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$10.00 | $30.00 | None | $9.00 |
Browse Plan Formulary |
Optimum Emerald Full (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$10.00 | $30.00 | None | $9.00 |
Browse Plan Formulary |
Optimum Emerald Partial (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$10.00 | $30.00 | None | $9.00 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $9.00 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $9.00 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete LP (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $9.00 |
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 Dual Liberty (HMO D-SNP)
|
$34.30 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$0.00 | $0.00 | None | $7.00 |
Browse Plan Formulary |
Wellcare Dual Select (HMO D-SNP)
|
$34.30 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$0.00 | $0.00 | None | $7.00 |
Browse Plan Formulary |
BlueMedicare Choice (Regional PPO)
|
$47.90 |
$250* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$10.00 | $30.00 | None | $10.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Freedom Platinum Plus Plan Rx (HMO)
|
$50.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $9.00 |
Browse Plan Formulary |
HumanaChoice R5826-005 (Regional PPO)
|
$55.00 |
$100* |
No |
2* |
Generic |
$15.00 | $0.00 | None | $9.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice Florida H7284-001 (PPO)
|
$85.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $0.00 | None | $9.00 |
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 |
Wellcare Premium Enhanced Open (PPO)
|
$90.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | None | $4.00 |
Browse Plan Formulary |
Humana Gold Choice H8145-061 (PFFS)
|
$102.00 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$17.00 | $0.00 | None | $9.00 |
Browse Plan Formulary |