SUBOXONE 12 MG-3 MG SL FILM (NDC: 12496121203)
2013 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
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 MedicareComplete Mosaic (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$92.00 | $266.00 | None | $445.19 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$92.00 | $266.00 | None | $445.19 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $445.19 |
Browse Plan Formulary |
Access Medicare Gold (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$70.00 | $105.00 | P Q:60 /30Days | $437.55 |
Browse Plan Formulary |
Amerivantage Balance + Rx (HMO)
|
$0.00 |
$0 | Some Generics | 4 |
Non-Preferred Brand |
$80.00 | $160.00 | P Q:60 /30Days | $461.12 |
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 |
Amerivantage Classic Choice + Rx Plan (HMO-POS)
|
$0.00 |
$0 | Some Generics | 4 |
Non-Preferred Brand |
$65.00 | $130.00 | P Q:60 /30Days | $461.12 |
Browse Plan Formulary |
Elderplan Classic: Zero Premium (HMO)
|
$0.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$90.00 | $225.00 | None | $433.52 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | P Q:60 /30Days | $449.40 |
Browse Plan Formulary |
Fidelis Medicare $0 Premium (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$75.00 | $150.00 | P Q:60 /30Days | $467.90 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$80.00 | $200.00 | P Q:60 /30Days | $456.25 |
Browse Plan Formulary |
Healthfirst Jade Benefits Plan (HMO)
|
$0.00 |
$0 | Many Generics, Few Brands | 3 |
Non-Preferred Brand |
$80.00 | $200.00 | P Q:60 /30Days | $456.25 |
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 |
PPO II (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$35.00 | $70.00 | Q:90 /30Days | $449.39 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (Regional PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $445.19 |
Browse Plan Formulary |
VIP (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$35.00 | $70.00 | Q:90 /30Days | $449.39 |
Browse Plan Formulary |
VIP (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$35.00 | $70.00 | Q:90 /30Days | $449.39 |
Browse Plan Formulary |
VIP (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$35.00 | $70.00 | Q:90 /30Days | $449.39 |
Browse Plan Formulary |
VIP Essential (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$35.00 | $70.00 | Q:90 /30Days | $449.39 |
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 |
VIP Essential (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$35.00 | $70.00 | Q:90 /30Days | $449.39 |
Browse Plan Formulary |
VIP Essential (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$35.00 | $70.00 | Q:90 /30Days | $449.39 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Enhanced (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$90.00 | $225.00 | P Q:60 /30Days | $454.68 |
Browse Plan Formulary |
WellCare Choice (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$79.00 | $158.00 | P | $455.28 |
Browse Plan Formulary |
WellCare Rx (HMO)
|
$1.60 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$79.00 | $158.00 | P | $455.28 |
Browse Plan Formulary |
WellCare Liberty (HMO SNP)
|
$20.60 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$95.00 | $190.00 | P | $455.28 |
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 Advocate Complete (HMO SNP)
|
$28.40 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$95.00 | $190.00 | P | $455.28 |
Browse Plan Formulary |
MetroPlus Platinum (HMO)
|
$34.70 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | P Q:60 /30Days | $455.90 |
Browse Plan Formulary |
Healthfirst Increased Benefits Plan (HMO)
|
$35.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | P Q:60 /30Days | $456.25 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$35.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $445.19 |
Browse Plan Formulary |
HHH Choices Gold (HMO SNP)
|
$39.70 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $434.08 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Preferred (HMO SNP)
|
$40.10 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | P Q:60 /30Days | $454.68 |
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 |
Elderplan Advantage For Nursing Home Residents (HMO SNP)
|
$40.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $433.52 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$40.40 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$95.00 | $190.00 | P | $455.28 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$41.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
n/a | n/a | None | $445.19 |
Browse Plan Formulary |
GuildNet Health Advantage (HMO-POS SNP)
|
$41.60 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | Q:90 /30Days | $449.39 |
Browse Plan Formulary |
MetroPlus Advantage Plan (HMO SNP)
|
$41.70 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | P Q:60 /30Days | $455.90 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete LP (HMO SNP)
|
$42.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | None | $445.19 |
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 |
Healthfirst AssuredCare (HMO SNP)
|
$43.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | P Q:60 /30Days | $456.25 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO SNP)
|
$43.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
n/a | n/a | P Q:60 /30Days | $456.25 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO SNP)
|
$43.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | P Q:60 /30Days | $456.25 |
Browse Plan Formulary |
Healthfirst Maximum Plan (HMO SNP)
|
$43.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
n/a | n/a | P Q:60 /30Days | $456.25 |
Browse Plan Formulary |
MetroPlus Select Plan (HMO SNP)
|
$43.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
n/a | n/a | P Q:60 /30Days | $455.90 |
Browse Plan Formulary |
Access Medicare Pearl (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | P Q:60 /30Days | $437.55 |
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 |
Access Medicare Platinum (HMO)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | P Q:60 /30Days | $437.55 |
Browse Plan Formulary |
Access Medicare Silver (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | P Q:60 /30Days | $437.55 |
Browse Plan Formulary |
Affinity Medicare Solutions (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | P Q:60 /30Days | $461.12 |
Browse Plan Formulary |
Affinity Medicare Ultimate (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Brand |
25% | 25% | P Q:60 /30Days | $461.12 |
Browse Plan Formulary |
Amerivantage Specialty + Rx (HMO SNP)
|
$43.20 |
$325 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
25% | 25% | P Q:60 /30Days | $461.12 |
Browse Plan Formulary |
ArchCare - Inst and IE SNP - All Counties (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | P Q:60 /30Days | $464.61 |
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 |
CenterLight Direct Complete Plan (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$42.00 | $126.00 | None | $460.25 |
Browse Plan Formulary |
CenterLight Direct Total Plan (HMO SNP)
|
$43.20 |
$185 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$45.00 | $135.00 | None | $460.25 |
Browse Plan Formulary |
Dual Eligible (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
25% | 25% | Q:90 /30Days | $449.39 |
Browse Plan Formulary |
Dual Eligible (PPO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
25% | 25% | Q:90 /30Days | $449.39 |
Browse Plan Formulary |
Elderplan Extra Help (HMO)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $433.52 |
Browse Plan Formulary |
Elderplan For Medicaid Beneficiaries (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $433.52 |
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 |
Elderplan Medicaid Advantage (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $433.52 |
Browse Plan Formulary |
Elderplan Plus Long Term Care (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $433.52 |
Browse Plan Formulary |
Fidelis Dual Advantage (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$70.00 | $140.00 | P Q:60 /30Days | $467.90 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO SNP)
|
$43.20 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | P Q:60 /30Days | $467.90 |
Browse Plan Formulary |
Fidelis Long Term Care Advantage (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | P Q:60 /30Days | $467.90 |
Browse Plan Formulary |
Fidelis Medicaid Advantage Plus (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$91.00 | $182.00 | P Q:60 /30Days | $467.90 |
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 |
Fidelis Medicare Advantage Flex (HMO-POS)
|
$43.20 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$70.00 | $140.00 | P Q:60 /30Days | $467.90 |
Browse Plan Formulary |
GuildNet Gold (HMO-POS SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
n/a | n/a | Q:90 /30Days | $449.39 |
Browse Plan Formulary |
Senior Whole Health of New York (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Brand |
$45.00 | $135.00 | Q:60 /30Days | $447.43 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$50.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | P Q:2 /1Days | $462.77 |
Browse Plan Formulary |
PPO III (PPO)
|
$54.50 |
$0 | All Generics | 2 |
Preferred Brand |
$35.00 | $70.00 | Q:90 /30Days | $449.39 |
Browse Plan Formulary |
MetroPlus Medicare Partnership in Care Plan (HMO SNP)
|
$67.10 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | P Q:60 /30Days | $455.90 |
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 |
VNSNY CHOICE Medicare Maximum (HMO SNP)
|
$78.50 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
n/a | n/a | P Q:60 /30Days | $454.68 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (HMO)
|
$80.00 |
$0 | Some Generics | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | P Q:2 /1Days | $462.77 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$85.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | P Q:2 /1Days | $462.77 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO SNP)
|
$95.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
n/a | n/a | P Q:60 /30Days | $454.68 |
Browse Plan Formulary |
PPO High Option (PPO)
|
$132.50 |
$0 | All Generics | 2 |
Preferred Brand |
$35.00 | $70.00 | Q:90 /30Days | $449.39 |
Browse Plan Formulary |
VIP High Option (HMO)
|
$157.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$35.00 | $70.00 | Q:90 /30Days | $449.39 |
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 |
VIP High Option (HMO)
|
$157.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$35.00 | $70.00 | Q:90 /30Days | $449.39 |
Browse Plan Formulary |
VIP High Option (HMO)
|
$157.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$35.00 | $70.00 | Q:90 /30Days | $449.39 |
Browse Plan Formulary |