MOXIFLOXACIN 0.5% EYE DROPS [Vigamox] (3 MLS ) (NDC: 65862084003)
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 Walgreens (HMO)
|
$0.00 |
$275 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $40.95 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Choice Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:12 /30Days | $45.84 |
Browse Plan Formulary |
Aetna Medicare Essential Plan (PPO)
|
$0.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:12 /30Days | $45.72 |
Browse Plan Formulary |
Aetna Medicare Plus Plan (PPO)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:12 /30Days | $46.17 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:12 /30Days | $45.51 |
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 (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | None | $41.88 |
Browse Plan Formulary |
Anthem MediBlue + Kroger Access (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | None | $41.88 |
Browse Plan Formulary |
Anthem MediBlue Access Basic (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | None | $43.53 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | $70.00 | None | $43.47 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Cigna Preferred GA Medicare (HMO)
|
$0.00 |
$280* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$42.00 | $126.00 | None | $30.78 |
Browse Plan Formulary |
Cigna Preferred GA Medicare (HMO)
|
$0.00 |
$280* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$42.00 | $126.00 | None | $32.40 |
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 |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $31.38 |
Browse Plan Formulary |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $31.38 |
Browse Plan Formulary |
Clover Health LiveHealthy (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$37.00 | $110.00 | None | $45.66 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Care Extra (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $29.46 |
Browse Plan Formulary |
Humana Gold Plus H4141-015 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $29.43 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice - Diabetes and Heart (PPO C-SNP)
|
$0.00 |
$145* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | None | $29.52 |
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 |
HumanaChoice H5216-154 (PPO)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $29.55 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5216-203 (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $29.55 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5216-203 (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $29.52 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Kaiser Permanente Senior Advantage Basic 1 (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $41.70 |
Browse Plan Formulary |
Sonder Complete Health Medicare Advantage (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $30.00 | None | $38.55 |
Browse Plan Formulary |
Sonder Diabetes Wellness (HMO C-SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $45.00 | None | $38.55 |
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 |
Sonder Heart Healthy (HMO C-SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $45.00 | None | $38.55 |
Browse Plan Formulary |
Wellcare Endurance Open (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | None | $40.32 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$400* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$5.00 | $0.00 | None | $40.32 |
Browse Plan Formulary |
Wellcare Giveback Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$37.00 | $74.00 | None | $44.55 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $0.00 | None | $39.36 |
Browse Plan Formulary |
Wellcare No Premium Focus (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $37.50 |
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 Medicare (HMO)
|
$0.00 |
$280* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$37.00 | $74.00 | None | $45.48 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
|
$0.00 |
$75* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$0.00 | $0.00 | None | $40.32 |
Browse Plan Formulary |
Wellcare Specialty No Premium (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
2 |
Generic |
$0.00 | $0.00 | None | $37.50 |
Browse Plan Formulary select insulin pay $10 copay but not this drug |
Humana Gold Plus H4141-017 (HMO)
|
$6.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $29.55 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H4141-017 (HMO)
|
$6.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $29.43 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H4141-017 (HMO)
|
$6.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $29.58 |
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 |
UnitedHealthcare Medicare Silver (Regional PPO C-SNP)
|
$9.20 |
$480 |
No |
4 |
Tier 4 |
25% | 25% | None | $47.52 |
Browse Plan Formulary |
UnitedHealthcare Medicare Gold (Regional PPO C-SNP)
|
$17.20 |
$210 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $47.52 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Dual Preferred Plan (HMO D-SNP)
|
$21.80 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:12 /30Days | $45.57 |
Browse Plan Formulary |
Humana Together in Health (PPO I-SNP)
|
$23.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $29.52 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H4141-003 (HMO D-SNP)
|
$23.90 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $29.52 |
Browse Plan Formulary |
Humana Care Extra (PPO D-SNP)
|
$24.20 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $29.46 |
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 Preferred Plus Medicare (HMO)
|
$25.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $32.16 |
Browse Plan Formulary |
HumanaChoice SNP-DE H5216-206 (PPO D-SNP)
|
$25.80 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $29.52 |
Browse Plan Formulary |
HumanaChoice SNP-DE H5216-205 (PPO D-SNP)
|
$28.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $29.52 |
Browse Plan Formulary |
Senior Advantage Medicare Medicaid Plan 1 (HMO D-SNP)
|
$29.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$14.00 | $0.00 | None | $41.70 |
Browse Plan Formulary |
Cigna TotalCare (HMO D-SNP)
|
$30.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $32.16 |
Browse Plan Formulary |
Cigna TotalCare Plus (HMO D-SNP)
|
$30.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | None | $32.16 |
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 Extra (HMO)
|
$30.50 |
$480 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $43.47 |
Browse Plan Formulary |
Anthem MediBlue + Kroger Dual Advantage (HMO D-SNP)
|
$32.40 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $41.88 |
Browse Plan Formulary |
Anthem MediBlue Dual Access (PPO D-SNP)
|
$32.40 |
$380 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $43.53 |
Browse Plan Formulary |
Anthem MediBlue Dual Advantage (HMO D-SNP)
|
$32.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $43.47 |
Browse Plan Formulary |
CareSource Dual Advantage (HMO D-SNP)
|
$32.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | 25% | None | $35.25 |
Browse Plan Formulary |
Clover Health LiveHealthy Value (PPO)
|
$32.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
22% | 22% | None | $45.66 |
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 H5216-280 (PPO)
|
$32.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $29.58 |
Browse Plan Formulary |
HumanaChoice H5216-280 (PPO)
|
$32.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $29.52 |
Browse Plan Formulary |
PruittHealth Premier (HMO I-SNP)
|
$32.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | Q:6 /7Days | $21.03 |
Browse Plan Formulary |
PruittHealth Premier D-SNP (HMO D-SNP)
|
$32.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | Q:6 /7Days | $20.67 |
Browse Plan Formulary |
Sonder Dual Complete (HMO D-SNP)
|
$32.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $60.00 | None | $38.55 |
Browse Plan Formulary |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$32.40 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $47.22 |
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 |
UnitedHealthcare Dual Complete (HMO-POS D-SNP)
|
$32.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $47.40 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (PPO D-SNP)
|
$32.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $47.22 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Choice LP (PPO D-SNP)
|
$32.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $47.40 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Choice Select LP (PPO D-SNP)
|
$32.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $47.40 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)
|
$32.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $47.37 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
|
$32.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $47.40 |
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 Assist (HMO)
|
$32.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $69.30 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
|
$32.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $69.30 |
Browse Plan Formulary |
Wellcare Dual Access Medicare (HMO D-SNP)
|
$32.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $43.17 |
Browse Plan Formulary |
Wellcare Dual Access Open (PPO D-SNP)
|
$32.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $80.00 | None | $69.30 |
Browse Plan Formulary |
Wellcare Dual Liberty (HMO D-SNP)
|
$32.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $80.00 | None | $69.30 |
Browse Plan Formulary |
Anthem MediBlue Essential (HMO)
|
$38.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $74.00 | None | $42.90 |
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 Choice H8145-069 (PFFS)
|
$44.00 |
$340 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $29.55 |
Browse Plan Formulary |
HumanaChoice H5216-073 (PPO)
|
$44.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $29.49 |
Browse Plan Formulary |
Aetna Medicare Advantra Preferred Plan (PPO)
|
$49.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:12 /30Days | $45.42 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice (Regional PPO)
|
$49.00 |
$295 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $47.52 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Low Premium Open (PPO)
|
$55.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$0.00 | $0.00 | None | $40.32 |
Browse Plan Formulary |
HumanaChoice R3392-002 (Regional PPO)
|
$55.80 |
$340 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $29.55 |
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 |
Anthem MediBlue Access (PPO)
|
$59.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | None | $43.53 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage Enhanced 1 (HMO)
|
$71.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $41.70 |
Browse Plan Formulary |
Wellcare Premium Enhanced Open (PPO)
|
$85.00 |
$75* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$0.00 | $0.00 | None | $40.32 |
Browse Plan Formulary |