ACYCLOVIR 5% OINTMENT [Zovirax] (15 GRAMS ) (NDC: 65162083594)
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 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:30 /30Days | $68.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Choice (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:30 /30Days | $68.25 |
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. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $67.95 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Focus (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:30 /30Days | $68.25 |
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 |
3 |
Non-Preferred Drug |
$60.00 | $120.00 | None | $72.90 |
Browse Plan Formulary select insulin pay $10 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 |
Advantage Care by Ultimate (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
3 |
Non-Preferred Drug |
$60.00 | $120.00 | None | $75.00 |
Browse Plan Formulary select insulin pay $10 copay but not this drug |
Advantage Care CHF by Ultimate (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
3 |
Non-Preferred Drug |
$60.00 | $120.00 | None | $73.35 |
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 |
3 |
Non-Preferred Drug |
$60.00 | $120.00 | None | $73.35 |
Browse Plan Formulary select insulin pay $10 copay but not this drug |
Aetna Medicare Credit (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $101.70 |
Browse Plan Formulary |
Aetna Medicare Premier (PPO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $108.75 |
Browse Plan Formulary |
Aetna Medicare Premier Plus (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:30 /30Days | $101.40 |
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 |
Aetna Medicare Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | Q:30 /30Days | $101.85 |
Browse Plan Formulary select insulin pay $20 copay but not this drug |
BayCarePlus Complete (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$4.00 | $0.00 | Q:30 /30Days | $30.45 |
Browse Plan Formulary select insulin pay $4-$35 copay but not this drug |
BayCarePlus Rewards (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $0.00 | Q:30 /30Days | $30.45 |
Browse Plan Formulary |
BlueMedicare Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $120.00 | P | $88.65 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BlueMedicare Premier (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | $90.00 | P | $95.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Bright Advantage Health Dollars Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $150.00 | Q:30 /30Days | $28.35 |
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 |
Bright Advantage Health Dollars Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:30 /30Days | $28.35 |
Browse Plan Formulary |
Bright Advantage Part B Savings Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:30 /30Days | $28.35 |
Browse Plan Formulary |
Bright Advantage Part B Savings Plan (PPO)
|
$0.00 |
$110 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:30 /30Days | $28.35 |
Browse Plan Formulary |
CareBreeze (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
4 |
Non-Preferred Drug |
$85.00 | $245.00 | P Q:30 /30Days | $13.50 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
CareComplete (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
4 |
Non-Preferred Drug |
$85.00 | $245.00 | P Q:30 /30Days | $13.50 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
CareFree (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$60.00 | $170.00 | P Q:30 /30Days | $13.50 |
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, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$60.00 | $170.00 | P Q:30 /30Days | $13.50 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
CareOne PLATINUM (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$55.00 | $155.00 | P Q:30 /30Days | $13.50 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
CareOne PLUS (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$45.00 | $125.00 | P Q:30 /30Days | $13.50 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
CareOne PLUS (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$45.00 | $125.00 | P Q:30 /30Days | $13.50 |
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 |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $48.15 |
Browse Plan Formulary |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $48.15 |
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 |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $48.15 |
Browse Plan Formulary |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
4 |
Non-Preferred Drug |
$35.00 | $95.00 | P Q:30 /30Days | $13.50 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
Humana Gold Plus H1036-025 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$55.00 | $155.00 | P Q:30 /30Days | $13.50 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
Humana Gold Plus H1036-265 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P Q:30 /30Days | $13.50 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
Humana Gold Plus H1036-265 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P Q:30 /30Days | $13.50 |
Browse Plan Formulary select insulin pay $20-$35 copay but not this drug |
HumanaChoice Florida H5216-072 (PPO)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days | $13.50 |
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 |
Premier by Ultimate (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Drug |
$60.00 | $120.00 | None | $72.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Premier by Ultimate (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Drug |
$60.00 | $120.00 | None | $72.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Premier Plus by Ultimate (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Drug |
$50.00 | $100.00 | None | $72.90 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
Premier Plus by Ultimate (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Drug |
$50.00 | $100.00 | None | $73.35 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
Simply Care (HMO I-SNP)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$5.00 | n/a | Q:30 /30Days | $99.60 |
Browse Plan Formulary |
Simply Comfort (HMO I-SNP)
|
$0.00 |
$480 |
Some Generics, Few Brands |
2 |
Generic |
$5.00 | n/a | Q:30 /30Days | $99.60 |
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 |
Simply Extra (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$10.00 | $0.00 | Q:30 /30Days | $99.60 |
Browse Plan Formulary |
Simply Level (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $99.60 |
Browse Plan Formulary |
Simply More (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $99.60 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150 |
Some Generics |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $52.05 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150 |
Some Generics |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $55.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150 |
Some Generics |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $54.30 |
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 Advantage Walgreens (HMO C-SNP)
|
$0.00 |
$150 |
Some Generics |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $53.55 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice R5826-074 (Regional PPO)
|
$0.50 |
$395 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days | $13.50 |
Browse Plan Formulary |
CareNeeds PLUS (HMO D-SNP)
|
$14.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days | $13.50 |
Browse Plan Formulary |
Humana Fully Integrated H1036-283 (HMO D-SNP)
|
$15.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days | $13.50 |
Browse Plan Formulary |
Cigna TotalCare Plus (HMO D-SNP)
|
$21.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
41% | 41% | Q:30 /30Days | $48.15 |
Browse Plan Formulary |
Cigna Primary Medicare (HMO)
|
$22.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
41% | 41% | Q:30 /30Days | $48.15 |
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 SNP-DE H1036-102 (HMO D-SNP)
|
$24.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days | $13.50 |
Browse Plan Formulary |
Aetna Medicare Assure (HMO D-SNP)
|
$28.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | Q:30 /30Days | $98.10 |
Browse Plan Formulary |
Aetna Medicare Assure Plus (HMO D-SNP)
|
$30.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
40% | 40% | Q:30 /30Days | $99.75 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP (Regional PPO D-SNP)
|
$31.50 |
$480 |
No |
4 |
Tier 4 |
15% | 15% | Q:30 /30Days | $67.95 |
Browse Plan Formulary |
BayCarePlus Premier (HMO)
|
$34.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | Q:30 /30Days | $30.45 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
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 | $73.35 |
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 |
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 | $73.35 |
Browse Plan Formulary |
BlueMedicare Complete (HMO D-SNP)
|
$34.30 |
$480 |
Some Generics, Few Brands |
3 |
Preferred Brand |
$40.00 | $120.00 | P | $91.35 |
Browse Plan Formulary |
Longevity Health Plan (HMO I-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | Q:30 /30Days | $18.00 |
Browse Plan Formulary |
Simply Complete (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $60.00 | Q:30 /30Days | $115.35 |
Browse Plan Formulary |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$34.30 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:30 /30Days | $68.25 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | Q:30 /30Days | $67.65 |
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 |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | Q:30 /30Days | $68.40 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete LP (HMO D-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | Q:30 /30Days | $68.10 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO I-SNP)
|
$34.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | Q:30 /30Days | $67.95 |
Browse Plan Formulary |
BlueMedicare Choice (Regional PPO)
|
$47.90 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $120.00 | P | $89.55 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice R5826-005 (Regional PPO)
|
$55.00 |
$100 |
No |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | P Q:30 /30Days | $13.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Choice H8145-061 (PFFS)
|
$102.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | P Q:30 /30Days | $13.50 |
Browse Plan Formulary |