EMSAM TRANSDERMAL SYSTEM PATCHES 6MG/24H (30 PATCHES CRTN) (NDC: 49502090030)
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 |
AARP MedicareComplete Plan 1 (HMO)
|
$0.00 |
$245* | No additional gap coverage, only the Donut Hole Discount | 5* |
Specialty Tier |
33% | 33% | None | $1,386.42 |
Browse Plan Formulary |
Affinity Medicare Passport Essentials (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,401.76 |
Browse Plan Formulary |
AgeWell New York FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
0% | 0% | None | $1,382.92 |
Browse Plan Formulary |
CenterLight Healthcare FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
0% | 0% | None | $1,397.80 |
Browse Plan Formulary |
EmblemHealth Dual Assurance FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
0% | 0% | None | $1,396.96 |
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 Dual Advantage (HMO SNP)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,395.77 |
Browse Plan Formulary |
Fidelis Fully Integrated Dual Advantage (FIDA) (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
0% | n/a | P Q:30 /30Days | $1,397.24 |
Browse Plan Formulary |
GuildNet Gold Plus FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
0% | 0% | None | $1,396.96 |
Browse Plan Formulary |
Healthfirst AbsoluteCare FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
0% | 0% | P Q:30 /30Days | $1,397.23 |
Browse Plan Formulary |
Integra FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
0% | 0% | Q:30 /30Days | $1,410.19 |
Browse Plan Formulary |
RiverSpring FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
0% | 0% | None | $1,417.34 |
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 Freedom (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$80.00 | $200.00 | Q:30 /30Days | $1,430.88 |
Browse Plan Formulary |
Touchstone Health Medicare Power (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$80.00 | $200.00 | Q:30 /30Days | $1,430.88 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (Regional PPO)
|
$0.00 |
$225* | No additional gap coverage, only the Donut Hole Discount | 5* |
Specialty Tier |
33% | 33% | None | $1,390.99 |
Browse Plan Formulary |
VNSNY CHOICE FIDA Complete (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
0% | 0% | Q:30 /30Days | $1,377.02 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Enhanced (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:30 /30Days | $1,376.71 |
Browse Plan Formulary |
WellCare Advocate Complete FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 4 |
Tier 4 |
0% | 0% | P Q:30 /30Days | $1,435.49 |
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)
|
$3.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | P | $1,397.27 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$28.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,441.54 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$30.30 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | None | $1,391.37 |
Browse Plan Formulary |
LiveWell (HMO)
|
$32.90 |
$250 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | 25% | None | $1,382.92 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Classic (HMO)
|
$34.10 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | Q:30 /30Days | $1,376.71 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO SNP)
|
$35.40 |
$320 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | n/a | P | $1,397.27 |
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 CompleteCare (HMO SNP)
|
$36.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | P Q:30 /30Days | $1,397.23 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO SNP)
|
$36.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | P Q:30 /30Days | $1,397.23 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Preferred (HMO SNP)
|
$36.30 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | Q:30 /30Days | $1,376.71 |
Browse Plan Formulary |
Affinity Medicare Solutions (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,401.76 |
Browse Plan Formulary |
Affinity Medicare Ultimate (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,401.76 |
Browse Plan Formulary |
ArchCare Advantage (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | P Q:30 /30Days | $1,412.79 |
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 |
BeWell (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $1,382.92 |
Browse Plan Formulary |
CareWell (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $1,382.92 |
Browse Plan Formulary |
CenterLight Healthcare Direct Complete Plan (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $135.00 | None | $1,397.80 |
Browse Plan Formulary |
EmblemHealth Dual Eligible (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | 25% | None | $1,396.96 |
Browse Plan Formulary |
EmblemHealth Dual Eligible (PPO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | 25% | None | $1,396.96 |
Browse Plan Formulary |
EmblemHealth MLTC PLUS (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | 25% | None | $1,396.96 |
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 |
FeelWell (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $1,382.92 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
|
$36.90 |
$240 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P | $1,397.27 |
Browse Plan Formulary |
Touchstone Health Medicare Grand (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | Q:30 /30Days | $1,430.88 |
Browse Plan Formulary |
Touchstone Health Medicare Prestige (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | Q:30 /30Days | $1,430.88 |
Browse Plan Formulary |
Touchstone Health Medicare Total (HMO)
|
$36.90 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$80.00 | $200.00 | Q:30 /30Days | $1,430.88 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Maximum (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | Q:30 /30Days | $1,376.71 |
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 Total (HMO SNP)
|
$36.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | Q:30 /30Days | $1,376.71 |
Browse Plan Formulary |
Affinity Medicare Passport Select (HMO)
|
$46.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,401.76 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$69.00 |
$240* | No additional gap coverage, only the Donut Hole Discount | 5* |
Specialty Tier |
33% | 33% | None | $1,386.42 |
Browse Plan Formulary |
Empire MediBlue Select (HMO)
|
$69.00 |
$273* | No additional gap coverage, only the Donut Hole Discount | 5* |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,403.44 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$94.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | S Q:30 /30Days | $1,405.30 |
Browse Plan Formulary |
GoldValue with Part D (HMO-POS)
|
$103.60 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $1,402.98 |
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)
|
$122.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $120.00 | None | $1,387.26 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
|
$122.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $120.00 | None | $1,432.12 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
|
$122.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $120.00 | None | $1,393.98 |
Browse Plan Formulary |
Affinity Medicare Passport Elite (HMO)
|
$126.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,401.76 |
Browse Plan Formulary |
Preferred Gold with Part D (HMO-POS)
|
$167.40 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$90.00 | $180.00 | None | $1,403.43 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
|
$173.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $120.00 | None | $1,387.26 |
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 (HMO)
|
$173.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $120.00 | None | $1,393.98 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
|
$173.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $120.00 | None | $1,432.12 |
Browse Plan Formulary |
EmblemHealth Advantage (PPO)
|
$199.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $120.00 | None | $1,387.26 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$328.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $120.00 | None | $1,387.26 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$328.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $120.00 | None | $1,432.12 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$328.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $120.00 | None | $1,393.98 |
Browse Plan Formulary |