ampicillin-sulbactam 3 gm vial (NDC: 00641612010)
2014 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 |
3 |
Preferred Brand |
$44.00 | $122.00 | None | $42.93 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$44.00 | $122.00 | None | $42.93 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $42.93 |
Browse Plan Formulary |
Access Medicare Gold (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$6.00 | $9.00 | None | $58.24 |
Browse Plan Formulary |
Advantage Health NYC - SNP (HMO SNP)
|
$0.00 |
$0 |
Some Generics |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $58.91 |
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 Silver - Queens (HMO)
|
$0.00 |
$0 |
Some Generics |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None | $58.91 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$0 |
Few Generics |
3 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $62.50 |
Browse Plan Formulary |
AlphaCare Renew (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$8.00 | n/a | None | $59.75 |
Browse Plan Formulary |
Amerivantage Balance + Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$4.00 | $8.00 | None | $60.84 |
Browse Plan Formulary |
Amida Care True Life Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$0.00 | $0.00 | None | $68.05 |
Browse Plan Formulary |
CPHL Advantage Care (HMO)
|
$0.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $59.75 |
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 |
Easy Choice Diamond Rewards (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$35.00 | $70.00 | P | $64.23 |
Browse Plan Formulary |
Easy Choice Rewards (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$39.00 | $78.00 | P | $64.23 |
Browse Plan Formulary |
Easy Choice Value (HMO)
|
$0.00 |
$0 |
Many Generics |
2 |
Preferred Brand |
$35.00 | $70.00 | P | $64.23 |
Browse Plan Formulary |
Elderplan Classic: Zero Premium (HMO)
|
$0.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$4.00 | $10.00 | P | $58.59 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P | $68.05 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P | $67.28 |
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 |
EmblemHealth Essential (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P | $68.29 |
Browse Plan Formulary |
EmblemHealth PPO II (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P | $68.05 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P | $68.05 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P | $67.28 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P | $68.29 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Injectable Drugs |
33% | 33% | None | $68.05 |
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 $0 Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$18.00 | $36.00 | None | $61.73 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$0.00 | $0.00 | None | $60.83 |
Browse Plan Formulary |
Humana Gold Plus H3533-009 (HMO)
|
$0.00 |
$0 |
Few Generics, Few Brands |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None | $87.16 |
Browse Plan Formulary |
Liberty Health Advantage Dual Power (HMO SNP)
|
$0.00 |
$310 |
to be determined |
4 |
Tier 4 |
15% | 15% | P | $58.90 |
Browse Plan Formulary |
Liberty Health Advantage Preferred Choice (HMO)
|
$0.00 |
$0 |
All Generics |
4 |
Non-Preferred Brand |
$75.00 | $225.00 | P | $58.90 |
Browse Plan Formulary |
Touchstone Health Medicare Freedom (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$80.00 | $200.00 | P | $58.90 |
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 |
Touchstone Health Medicare Power (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$80.00 | $200.00 | P | $58.90 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (Regional PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $43.19 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Enhanced (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None | $60.17 |
Browse Plan Formulary |
WellCare Choice (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $62.81 |
Browse Plan Formulary |
Humana Gold Plus HMO-SNP-DE H3533-004 (HMO SNP)
|
$12.20 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $87.16 |
Browse Plan Formulary |
WellCare Rx (HMO)
|
$22.90 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35.00 | $70.00 | None | $64.42 |
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 (HMO SNP)
|
$24.10 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
n/a | n/a | None | $43.15 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$28.30 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | None | $43.15 |
Browse Plan Formulary |
Healthfirst Increased Benefits Plan (HMO)
|
$30.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $60.83 |
Browse Plan Formulary |
Advantage Value One NY - Dual (HMO SNP)
|
$31.10 |
$0 |
Some Generics |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $48.89 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Maximum (HMO SNP)
|
$31.50 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
n/a | n/a | None | $60.17 |
Browse Plan Formulary |
GuildNet Health Advantage (HMO-POS SNP)
|
$33.10 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | P | $68.21 |
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 Total Plan (HMO SNP)
|
$33.90 |
$310* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$9.00 | $27.00 | None | $68.05 |
Browse Plan Formulary |
CenterLight Healthcare Direct Complete Plan (HMO SNP)
|
$34.00 |
$310* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$7.25 | $21.75 | None | $68.05 |
Browse Plan Formulary |
EmblemHealth Dual Eligible (HMO SNP)
|
$34.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$9.00 | $27.00 | P | $68.05 |
Browse Plan Formulary |
EmblemHealth Dual Eligible (PPO SNP)
|
$34.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$9.00 | $27.00 | P | $68.06 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$36.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$20.00 | $40.00 | None | $64.42 |
Browse Plan Formulary |
Access Medicare Pearl (HMO SNP)
|
$37.20 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $58.24 |
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)
|
$37.20 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $58.24 |
Browse Plan Formulary |
Affinity Medicare Solutions (HMO SNP)
|
$37.20 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $60.39 |
Browse Plan Formulary |
Affinity Medicare Ultimate (HMO SNP)
|
$37.20 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $60.39 |
Browse Plan Formulary |
AlphaCare Resilience (HMO SNP)
|
$37.20 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | None | $59.75 |
Browse Plan Formulary |
AlphaCare Total (HMO SNP)
|
$37.20 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | n/a | None | $59.75 |
Browse Plan Formulary |
Amerivantage Specialty + Rx (HMO SNP)
|
$37.20 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
n/a | n/a | None | $60.84 |
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 |
Amida Care Live Life Advantage (HMO SNP)
|
$37.20 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $68.05 |
Browse Plan Formulary |
Amida Care True Life Advantage (HMO SNP)
|
$37.20 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $68.05 |
Browse Plan Formulary |
ArchCare Advantage (HMO SNP)
|
$37.20 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $62.30 |
Browse Plan Formulary |
Elderplan Advantage For Nursing Home Residents (HMO SNP)
|
$37.20 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | P | $58.59 |
Browse Plan Formulary |
Elderplan Extra Help (HMO)
|
$37.20 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | P | $58.59 |
Browse Plan Formulary |
Elderplan For Medicaid Beneficiaries (HMO SNP)
|
$37.20 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P | $58.59 |
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 Plus Long Term Care (HMO SNP)
|
$37.20 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P | $58.59 |
Browse Plan Formulary |
Fidelis Dual Advantage (HMO SNP)
|
$37.20 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$16.00 | $32.00 | None | $61.73 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO SNP)
|
$37.20 |
$310 |
Some Generics |
2 |
Non-Preferred Generic |
$23.00 | $46.00 | None | $60.08 |
Browse Plan Formulary |
Fidelis Medicaid Advantage Plus (HMO SNP)
|
$37.20 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$29.00 | $58.00 | None | $62.21 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
|
$37.20 |
$240* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$15.00 | $30.00 | None | $60.08 |
Browse Plan Formulary |
GuildNet Gold (HMO-POS SNP)
|
$37.20 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
n/a | n/a | P | $68.21 |
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)
|
$37.20 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $60.83 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO SNP)
|
$37.20 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
n/a | n/a | None | $60.50 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO SNP)
|
$37.20 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $60.50 |
Browse Plan Formulary |
Healthfirst Maximum Plan (HMO SNP)
|
$37.20 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
n/a | n/a | None | $60.50 |
Browse Plan Formulary |
MetroPlus Advantage Plan (HMO SNP)
|
$37.20 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $63.22 |
Browse Plan Formulary |
MetroPlus Select Plan (HMO SNP)
|
$37.20 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
n/a | n/a | None | $63.22 |
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 |
Senior Whole Health of New York (HMO SNP)
|
$37.20 |
$310* |
Call plan for details |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $68.05 |
Browse Plan Formulary |
Senior Whole Health of New York NHC (HMO SNP)
|
$37.20 |
$310* |
Call plan for details |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $68.05 |
Browse Plan Formulary |
Touchstone Health Medicare Grand (HMO SNP)
|
$37.20 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
n/a | n/a | P | $58.90 |
Browse Plan Formulary |
Touchstone Health Medicare Prestige (HMO SNP)
|
$37.20 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
n/a | n/a | P | $58.90 |
Browse Plan Formulary |
Touchstone Health Medicare Prestige Plus (HMO SNP)
|
$37.20 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
n/a | n/a | P | $58.90 |
Browse Plan Formulary |
Touchstone Health Medicare Total (HMO)
|
$37.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$80.00 | $200.00 | P | $58.90 |
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 Classic (HMO)
|
$37.20 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $60.17 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Preferred (HMO SNP)
|
$37.20 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $60.17 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO SNP)
|
$37.20 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
n/a | n/a | None | $60.17 |
Browse Plan Formulary |
Elderplan Medicaid Advantage (HMO SNP)
|
$37.40 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P | $58.59 |
Browse Plan Formulary |
Fidelis Long Term Care Advantage (HMO SNP)
|
$44.50 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $60.17 |
Browse Plan Formulary |
MetroPlus Platinum (HMO)
|
$47.90 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $63.22 |
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 Platinum Plus NY (HMO)
|
$63.00 |
$0 |
Some Generics |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $48.89 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$87.00 |
$0 |
Few Generics |
3 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $62.44 |
Browse Plan Formulary |
EmblemHealth PPO III (PPO)
|
$89.00 |
$0 |
All Generics |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P | $68.05 |
Browse Plan Formulary |
MetroPlus Medicare Partnership in Care Plan (HMO SNP)
|
$134.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $63.22 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$161.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P | $68.29 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$161.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P | $68.05 |
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 |
EmblemHealth VIP High Option (HMO)
|
$161.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | P | $67.28 |
Browse Plan Formulary |