CARDENE IV INJECTION 2.5MG/ML 10 X 10 ML AMP (10 X 10 ML AMP) (NDC: 24477003025)
2010 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
Plan Name |
Monthly Prem. |
De- duct- ible |
Does Plan Offer 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 |
Elderplan Classic I: Medicare Extra Needs
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $2,306.27 |
Browse Plan Formulary |
Elderplan Classic I: Medicare Extra Needs
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $2,306.27 |
Browse Plan Formulary |
Elderplan Classic I: Medicare Extra Needs
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $2,306.27 |
Browse Plan Formulary |
Elderplan Classic I: Medicare Extra Needs
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $2,306.27 |
Browse Plan Formulary |
Elderplan Classic I: Medicare Extra Needs
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $2,306.27 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Elderplan Classic II: Medicare Zero Premiu
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $2,306.27 |
Browse Plan Formulary |
Elderplan Medicare Part B Premium Reductio
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,306.27 |
Browse Plan Formulary |
Elderplan Medicare Part B Premium Reductio
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,306.27 |
Browse Plan Formulary |
Elderplan Medicare Part B Premium Reductio
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,306.27 |
Browse Plan Formulary |
Elderplan Medicare Part B Premium Reductio
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,306.27 |
Browse Plan Formulary |
Elderplan Medicare Part B Premium Reductio
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,306.27 |
Browse Plan Formulary |
|
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
GHI Medicare PPO Any Dual (PPO)
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
40% | 40% | P | $2,467.78 |
Browse Plan Formulary |
GHI Medicare PPO II (PPO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
GHI Medicare PPO Value (PPO)
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
40% | 40% | P | $2,467.78 |
Browse Plan Formulary |
GHI Medicare PPO Value (PPO)
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
40% | 40% | P | $2,467.78 |
Browse Plan Formulary |
GHI Medicare PPO Value (PPO)
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
40% | 40% | P | $2,467.78 |
Browse Plan Formulary |
GHI Medicare PPO Value (PPO)
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
40% | 40% | P | $2,467.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
GHI Medicare PPO Value (PPO)
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
40% | 40% | P | $2,467.78 |
Browse Plan Formulary |
GHI Medicare PPO Value (PPO)
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
40% | 40% | P | $2,467.78 |
Browse Plan Formulary |
GHI Medicare PPO Value (PPO)
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
40% | 40% | P | $2,467.78 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,082.38 |
Browse Plan Formulary |
Healthfirst Medicare Plus Plan (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$60.00 | $150.00 | None | $2,082.38 |
Browse Plan Formulary |
HIP VIP (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HIP VIP (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Dual Eligible (HMO)
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
40% | 40% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Medicaid Advantage (HMO)
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
40% | 40% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Medicaid Advantage (HMO)
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
40% | 40% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Medicaid Advantage (HMO)
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
40% | 40% | P | $2,467.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HIP VIP Medicaid Advantage (HMO)
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
40% | 40% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Medicaid Advantage (HMO)
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
40% | 40% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Medicaid Advantage (HMO)
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
40% | 40% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Medicaid Advantage (HMO)
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
40% | 40% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Medicaid Advantage (HMO)
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
40% | 40% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Medicaid Advantage (HMO)
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
40% | 40% | P | $2,467.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HIP VIP Medicaid Advantage (HMO)
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
40% | 40% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Medicaid Advantage (HMO)
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
40% | 40% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Medicaid Advantage (HMO)
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
40% | 40% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Medicaid Advantage (HMO)
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
40% | 40% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Medicaid Advantage (HMO)
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
40% | 40% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Medicaid Advantage (HMO)
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
40% | 40% | P | $2,467.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HIP VIP Medicaid Advantage (HMO)
|
$0.00 |
$310 |
to be determined |
3 |
Tier 3 |
40% | 40% | P | $2,467.78 |
Browse Plan Formulary |
MediBlue Plus (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
MediBlue Value (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
MediBlue Value (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
MediBlue Value (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
MediBlue Value (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
MediBlue Value (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
MediBlue Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
MediBlue Plus (PPO)
|
$2.60 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
Medicare Blue PPO Plan ONE (PPO)
|
$5.50 |
$150 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $2,458.52 |
Browse Plan Formulary |
Medicare Blue PPO Plan ONE (PPO)
|
$5.50 |
$150 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $2,458.52 |
Browse Plan Formulary |
Medicare Blue PPO Plan ONE (PPO)
|
$5.50 |
$150 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $2,458.52 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
GHI Medicare PPO II (PPO)
|
$10.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
GHI Medicare PPO II (PPO)
|
$15.20 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
GHI Medicare PPO II (PPO)
|
$15.20 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
GHI Medicare PPO II (PPO)
|
$15.20 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-002 (PFFS)
|
$17.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $2,416.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Medicare Blue PPO Plan ONE (PPO)
|
$19.00 |
$150 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $2,458.52 |
Browse Plan Formulary |
Medicare Blue PPO Plan ONE (PPO)
|
$19.00 |
$150 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $2,458.52 |
Browse Plan Formulary |
Medicare Blue PPO Plan ONE (PPO)
|
$19.00 |
$150 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $2,458.52 |
Browse Plan Formulary |
Medicare Blue PPO Plan ONE (PPO)
|
$19.00 |
$150 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $2,458.52 |
Browse Plan Formulary |
Medicare Blue PPO Plan ONE (PPO)
|
$19.00 |
$150 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $2,458.52 |
Browse Plan Formulary |
Medicare Blue PPO Plan ONE (PPO)
|
$19.30 |
$150 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $2,458.52 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Medicare Blue PPO Plan ONE (PPO)
|
$19.30 |
$150 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $2,458.52 |
Browse Plan Formulary |
Medicare Blue PPO Plan ONE (PPO)
|
$19.30 |
$150 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $2,458.52 |
Browse Plan Formulary |
Humana Gold Choice H4774-004 (PFFS)
|
$20.90 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
HIP VIP Plus (HMO)
|
$22.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Plus (HMO)
|
$22.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Plus (HMO)
|
$22.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HIP VIP Plus (HMO)
|
$22.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Plus (HMO)
|
$22.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Plus (HMO)
|
$22.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Plus (HMO)
|
$22.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Plus (HMO)
|
$22.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Plus (HMO)
|
$22.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HIP VIP Plus (HMO)
|
$22.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Plus (HMO)
|
$22.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Plus (HMO)
|
$22.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Plus (HMO)
|
$22.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Plus (HMO)
|
$22.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Plus (HMO)
|
$22.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HIP VIP Plus (HMO)
|
$22.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Plus (HMO)
|
$22.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Plus (HMO)
|
$22.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Plus (HMO)
|
$22.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Plus (HMO)
|
$22.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Plus (HMO)
|
$22.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HIP VIP Plus (HMO)
|
$22.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Plus (HMO)
|
$22.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
HIP VIP Plus (HMO)
|
$22.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |
Evercare Plan IH (HMO)
|
$27.70 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,528.63 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
GHI Medicare PPO III (PPO)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
Evercare Plan IH (HMO)
|
$29.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $2,528.63 |
Browse Plan Formulary |
Humana Gold Choice H4774-003 (PFFS)
|
$29.60 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-005 (PFFS)
|
$29.90 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,416.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Elderplan Medicare Extra Help (HMO)
|
$30.60 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,306.27 |
Browse Plan Formulary |
Elderplan Medicare For Nursing Home Reside
|
$30.60 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,306.27 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Humana Gold Choice H4774-001 (PFFS)
|
$30.80 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $2,416.68 |
Browse Plan Formulary |
Elderplan Medicare Premium Benefit (HMO-PO
|
$31.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $2,306.27 |
Browse Plan Formulary |
GHI Medicare PPO III (PPO)
|
$31.40 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Healthfirst Increased Benefits Plan (HMO)
|
$33.00 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,082.38 |
Browse Plan Formulary |
Healthfirst Increased Benefits Plan (HMO)
|
$33.00 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $2,082.38 |
Browse Plan Formulary |
GuildNet Gold (HMO-POS)
|
$33.30 |
$310 |
to be determined |
3 |
Tier 3 |
$95.00 | $285.00 | P | $2,467.78 |
Browse Plan Formulary |
Health Plus Elite - Dual Special Needs Pla
|
$33.30 |
$310 |
to be determined |
2 |
Tier 2 |
n/a | n/a | None | $2,479.93 |
Browse Plan Formulary |
Health Plus Elite - MAPD (HMO)
|
$33.30 |
$310 |
to be determined |
2 |
Tier 2 |
25% | 25% | None | $2,479.93 |
Browse Plan Formulary |
Medicare Blue PPO - TWO (PPO)
|
$37.10 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $2,458.52 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Medicare Blue PPO - TWO (PPO)
|
$37.10 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $2,458.52 |
Browse Plan Formulary |
Medicare Blue PPO - TWO (PPO)
|
$37.10 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $2,458.52 |
Browse Plan Formulary |
Medicare Blue PPO - TWO (PPO)
|
$37.10 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $2,458.52 |
Browse Plan Formulary |
Medicare Blue PPO - TWO (PPO)
|
$37.10 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $2,458.52 |
Browse Plan Formulary |
Medicare Blue PPO - TWO (PPO)
|
$37.10 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $2,458.52 |
Browse Plan Formulary |
Medicare Blue PPO - TWO (PPO)
|
$37.10 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $2,458.52 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Medicare Blue PPO - TWO (PPO)
|
$37.10 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $2,458.52 |
Browse Plan Formulary |
Advantage Platinum NY - Suffolk (HMO)
|
$41.20 |
$0 |
to be determined |
4 |
Tier 4 |
25% | n/a | None | $2,528.30 |
Browse Plan Formulary |
Advantage Health Suffolk - SNP (HMO)
|
$44.30 |
$0 |
to be determined |
4 |
Tier 4 |
25% | n/a | None | $2,528.30 |
Browse Plan Formulary |
GHI Medicare PPO III (PPO)
|
$45.80 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
GHI Medicare PPO III (PPO)
|
$45.80 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
GHI Medicare PPO III (PPO)
|
$45.80 |
$0 |
to be determined |
3 |
Tier 3 |
50% | 50% | P | $2,467.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
MediBlue Plus (PPO)
|
$70.20 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $2,114.37 |
Browse Plan Formulary |