CARTIA XT 120MG CAPSULE SA (90 BOT) (NDC: 62037059790)
2015 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 |
Advantage Health NY - SNP (HMO SNP)
![Email Prescription and/or Health Benefit details for Advantage Health NY - SNP (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$10.00 | $20.00 | None | $19.04 |
Browse Plan Formulary |
Advantage Silver - NY (HMO)
![Email Prescription and/or Health Benefit details for Advantage Silver - NY (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$15.00 | $30.00 | None | $19.16 |
Browse Plan Formulary |
Aetna Better Health FIDA Plan (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for Aetna Better Health FIDA Plan (Medicare-Medicaid Plan)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | 0% | None | $18.22 |
Browse Plan Formulary |
Affinity Medicare Passport Essentials (HMO)
![Email Prescription and/or Health Benefit details for Affinity Medicare Passport Essentials (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $112.50 | None | $15.58 |
Browse Plan Formulary |
AgeWell New York FIDA (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for AgeWell New York FIDA (Medicare-Medicaid Plan)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | 0% | None | $13.86 |
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 Healthcare FIDA Plan (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for CenterLight Healthcare FIDA Plan (Medicare-Medicaid Plan)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | 0% | None | $24.10 |
Browse Plan Formulary |
EmblemHealth Dual Assurance FIDA Plan (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for EmblemHealth Dual Assurance FIDA Plan (Medicare-Medicaid Plan)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | 0% | None | $16.69 |
Browse Plan Formulary |
Fidelis Fully Integrated Dual Advantage (FIDA) (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for Fidelis Fully Integrated Dual Advantage (FIDA) (Medicare-Medicaid Plan)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | n/a | None | $19.43 |
Browse Plan Formulary |
GuildNet Gold Plus FIDA Plan (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for GuildNet Gold Plus FIDA Plan (Medicare-Medicaid Plan)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | 0% | None | $16.69 |
Browse Plan Formulary |
Integra FIDA Plan (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for Integra FIDA Plan (Medicare-Medicaid Plan)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | 0% | None | $25.78 |
Browse Plan Formulary |
North Shore-LIJ FIDA LiveWell (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for North Shore-LIJ FIDA LiveWell (Medicare-Medicaid Plan)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | 0% | None | $14.86 |
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 |
RiverSpring FIDA Plan (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for RiverSpring FIDA Plan (Medicare-Medicaid Plan)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | None | $32.25 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (Regional PPO)
![Email Prescription and/or Health Benefit details for UnitedHealthcare MedicareComplete Choice (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$225 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $12.43 |
Browse Plan Formulary |
VNSNY CHOICE FIDA Complete (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for VNSNY CHOICE FIDA Complete (Medicare-Medicaid Plan)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | 0% | None | $15.77 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Enhanced (HMO)
![Email Prescription and/or Health Benefit details for VNSNY CHOICE Medicare Enhanced (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$9.00 | $27.00 | None | $15.77 |
Browse Plan Formulary |
WellCare Advocate Complete FIDA (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for WellCare Advocate Complete FIDA (Medicare-Medicaid Plan)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
0% | 0% | None | $18.08 |
Browse Plan Formulary |
WellCare Choice (HMO)
![Email Prescription and/or Health Benefit details for WellCare Choice (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$43.00 | $107.50 | None | $18.62 |
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 Long Term Care Advantage (HMO SNP)
![Email Prescription and/or Health Benefit details for Fidelis Long Term Care Advantage (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$3.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $19.43 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Nursing Home Plan (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$30.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | None | $12.46 |
Browse Plan Formulary |
LiveWell (HMO)
![Email Prescription and/or Health Benefit details for LiveWell (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$32.90 |
$250 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $13.86 |
Browse Plan Formulary |
Humana Gold Plus H3533-010 (HMO)
![Email Prescription and/or Health Benefit details for Humana Gold Plus H3533-010 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$33.00 |
$320* |
Yes, but No Gap Coverage for this drug. |
2* |
Non-Preferred Generic |
$25.00 | $0.00 | Q:60 /30Days | $17.09 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Classic (HMO)
![Email Prescription and/or Health Benefit details for VNSNY CHOICE Medicare Classic (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$34.10 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $15.77 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO SNP)
![Email Prescription and/or Health Benefit details for Fidelis Dual Advantage Flex (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$35.40 |
$320 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$21.00 | $42.00 | None | $19.43 |
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 Preferred (HMO SNP)
![Email Prescription and/or Health Benefit details for VNSNY CHOICE Medicare Preferred (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $15.77 |
Browse Plan Formulary |
Advantage Value One NY - Dual (HMO SNP)
![Email Prescription and/or Health Benefit details for Advantage Value One NY - Dual (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.90 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Tier 2 |
$10.00 | $20.00 | None | $19.05 |
Browse Plan Formulary |
Affinity Medicare Solutions (HMO SNP)
![Email Prescription and/or Health Benefit details for Affinity Medicare Solutions (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | None | $15.58 |
Browse Plan Formulary |
Affinity Medicare Ultimate (HMO SNP)
![Email Prescription and/or Health Benefit details for Affinity Medicare Ultimate (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $112.50 | None | $15.58 |
Browse Plan Formulary |
BeWell (HMO SNP)
![Email Prescription and/or Health Benefit details for BeWell (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $13.86 |
Browse Plan Formulary |
CareWell (HMO SNP)
![Email Prescription and/or Health Benefit details for CareWell (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $13.86 |
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 Healthcare Direct Complete Plan (HMO SNP)
![Email Prescription and/or Health Benefit details for CenterLight Healthcare Direct Complete Plan (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.90 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$7.25 | $21.75 | None | $24.10 |
Browse Plan Formulary |
EmblemHealth Dual Eligible (HMO SNP)
![Email Prescription and/or Health Benefit details for EmblemHealth Dual Eligible (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$9.00 | $27.00 | None | $16.69 |
Browse Plan Formulary |
EmblemHealth Dual Eligible (PPO SNP)
![Email Prescription and/or Health Benefit details for EmblemHealth Dual Eligible (PPO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$9.00 | $27.00 | None | $16.69 |
Browse Plan Formulary |
EmblemHealth MLTC PLUS (HMO SNP)
![Email Prescription and/or Health Benefit details for EmblemHealth MLTC PLUS (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$9.00 | $27.00 | None | $16.69 |
Browse Plan Formulary |
FeelWell (HMO SNP)
![Email Prescription and/or Health Benefit details for FeelWell (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $13.86 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
![Email Prescription and/or Health Benefit details for Fidelis Medicare Advantage Flex (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.90 |
$240* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$15.00 | $30.00 | None | $19.43 |
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 |
GuildNet Gold (HMO-POS SNP)
![Email Prescription and/or Health Benefit details for GuildNet Gold (HMO-POS SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $16.72 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Maximum (HMO SNP)
![Email Prescription and/or Health Benefit details for VNSNY CHOICE Medicare Maximum (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $15.77 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO SNP)
![Email Prescription and/or Health Benefit details for VNSNY CHOICE Total (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $15.77 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
![Email Prescription and/or Health Benefit details for WellCare Access (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $100.00 | None | $18.05 |
Browse Plan Formulary |
Affinity Medicare Passport Select (HMO)
![Email Prescription and/or Health Benefit details for Affinity Medicare Passport Select (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$46.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $105.00 | None | $15.58 |
Browse Plan Formulary |
Advantage Platinum Plus NY (HMO)
![Email Prescription and/or Health Benefit details for Advantage Platinum Plus NY (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$49.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Tier 2 |
$10.00 | $20.00 | None | $19.05 |
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 |
Empire MediBlue Freedom I (PPO)
![Email Prescription and/or Health Benefit details for Empire MediBlue Freedom I (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$71.00 |
$304 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$22.00 | $44.00 | None | $21.40 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
![Email Prescription and/or Health Benefit details for Empire MediBlue Plus (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$80.00 |
$315 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$23.00 | $46.00 | None | $21.29 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth Essential (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$122.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $16.71 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth Essential (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$122.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $16.63 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth Essential (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$122.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $16.64 |
Browse Plan Formulary |
Affinity Medicare Passport Elite (HMO)
![Email Prescription and/or Health Benefit details for Affinity Medicare Passport Elite (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$126.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | None | $15.58 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Plus H3533-019 (HMO)
![Email Prescription and/or Health Benefit details for Humana Gold Plus H3533-019 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$163.00 |
$320* |
Yes, but No Gap Coverage for this drug. |
2* |
Non-Preferred Generic |
$18.00 | $0.00 | Q:60 /30Days | $17.09 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$173.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $16.71 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$173.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $16.63 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$173.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $16.64 |
Browse Plan Formulary |
EmblemHealth Advantage (PPO)
![Email Prescription and/or Health Benefit details for EmblemHealth Advantage (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$199.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $16.63 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP High Option (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$328.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $16.64 |
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)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP High Option (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$328.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $16.71 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP High Option (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$328.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $16.63 |
Browse Plan Formulary |