POLYCIN EYE OINTMENT [Polytracin] (3.5 GRAMS ) (NDC: 00574402135)
2023 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 Plan 4 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$12.00 | $0.00 | None | $22.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 7 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$12.00 | $0.00 | None | $17.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier (HMO-POS)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $16.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$10.00 | $20.00 | None | $22.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | None | $13.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | None | $14.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | None | $13.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | None | $14.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-285 (PPO)
|
$0.00 |
$200* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $0.00 | None | $11.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-309 (PPO)
|
$0.00 |
$350* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $0.00 | None | $11.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-042 (PPO)
|
$0.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$17.00 | $0.00 | None | $11.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
|
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 |
MAP Medicare (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$8.00 | $16.00 | None | $14.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
MediGold Mount Carmel Cash Back No Premium (HMO)
|
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$10.00 | $0.00 | None | $19.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
MediGold Mount Carmel No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | None | $18.56 |
Browse Plan Formulary all covered insulin pay $35 or less |
MediGold Mount Carmel No Premium Choice (PPO)
|
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$10.00 | $0.00 | None | $18.56 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $0.00 | None | $13.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $0.00 | None | $15.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 Classic (HMO)
|
$0.00 |
$95* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $0.00 | None | $16.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$3.00 | $6.00 | None | $14.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Choice Care Select (HMO)
|
$0.00 |
$375 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$15.00 | $30.00 | None | $14.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
Paramount Elite Standard (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$8.00 | $16.00 | None | $13.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dividend Giveback (HMO)
|
$0.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $0.00 | None | $4.87 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback (HMO)
|
$0.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $0.00 | None | $4.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 Giveback Boost (HMO)
|
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$9.00 | $0.00 | None | $4.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
|
$0.00 |
$75* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$9.00 | $0.00 | None | $4.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Essential (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $3.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Medicare (HMO)
|
$0.00 |
$75* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$9.00 | $0.00 | None | $4.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$160* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$7.00 | $0.00 | None | $4.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Extra (HMO)
|
$10.40 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $60.00 | None | $13.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
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)
|
$10.80 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $0.00 | None | $5.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist Complement (HMO)
|
$11.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $0.00 | None | $5.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Plan 1 (HMO-POS)
|
$19.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $0.00 | None | $17.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Flex Plan 8 (HMO-POS)
|
$25.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | None | $17.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Value Plus H5525-041 (PPO)
|
$25.90 |
$260 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $0.00 | None | $11.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$26.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $9.05 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 |
Paramount Elite Prime (HMO)
|
$28.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$10.00 | $20.00 | None | $13.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$28.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $9.05 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Extra (HMO-POS D-SNP)
|
$28.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $9.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Dual Advantage (HMO D-SNP)
|
$28.90 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $60.00 | None | $13.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage Choice Flex (PPO)
|
$30.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$8.00 | $0.00 | None | $22.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
CareSource Dual Advantage (HMO D-SNP)
|
$34.70 |
$505 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
25% | 25% | None | $12.48 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 SNP-DE H5525-046 (PPO D-SNP)
|
$34.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $11.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Complete Care (HMO D-SNP)
|
$34.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$4.00 | $12.00 | None | $14.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$34.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$0.00 | $0.00 | None | $14.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete (HMO-POS D-SNP)
|
$34.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $22.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Choice (PPO D-SNP)
|
$34.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $15.81 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Dual Complete Select (HMO-POS D-SNP)
|
$34.70 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $22.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 |
Paramount Elite Preferred PPO (PPO)
|
$65.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$10.00 | $20.00 | None | $13.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Paramount Elite Enhanced (HMO)
|
$68.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $13.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
SummaCare Medicare Sapphire (HMO-POS)
|
$76.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$8.00 | $20.00 | None | $14.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Access Basic (Regional PPO)
|
$78.00 |
$50* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$15.00 | $0.00 | None | $13.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-050 (PPO)
|
$79.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$5.00 | $0.00 | None | $11.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R5495-002 (Regional PPO)
|
$84.00 |
$505* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$20.00 | $0.00 | None | $11.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
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)
|
$100.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $13.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Choice (HMO)
|
$100.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $15.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Choice (HMO)
|
$100.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $16.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Select (PPO)
|
$100.00 |
$95* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $13.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Select (PPO)
|
$100.00 |
$95* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $15.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Select (PPO)
|
$100.00 |
$95* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $16.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 Plus (HMO)
|
$134.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $13.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Plus (HMO)
|
$134.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $15.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Plus (HMO)
|
$134.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $16.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plus 2 (Regional PPO)
|
$137.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $25.00 | None | $18.95 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5525-030 (PPO)
|
$150.00 |
$100* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$4.00 | $0.00 | None | $11.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Preferred (PPO)
|
$150.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $16.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 Preferred (PPO)
|
$150.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $13.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Preferred (PPO)
|
$150.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $15.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plus 1 (Regional PPO)
|
$198.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $15.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Premium (PPO)
|
$200.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $13.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Premium (PPO)
|
$200.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $15.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
MedMutual Advantage Premium (PPO)
|
$200.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $16.98 |
Browse Plan Formulary all covered insulin pay $35 or less |