Levothyroxine Sodium 200ug/1 100 BOTTLE, PLASTIC in 1 BOTTLE, PLASTIC / 100 TABLET BOTTLE, PLA (100 BOTTLE, PLASTIC in 1 ) (NDC: 00378181901)
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 |
1* |
Preferred Generic |
$2.00 | $4.00 | None | $18.43 |
Browse Plan Formulary |
Affinity Medicare Passport Essentials (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $19.22 |
Browse Plan Formulary |
AgeWell New York FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | 0% | None | $17.93 |
Browse Plan Formulary |
CenterLight Healthcare FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | 0% | None | $20.49 |
Browse Plan Formulary |
EmblemHealth Dual Assurance FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | 0% | None | $20.37 |
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 |
1* |
Preferred Generic |
$5.00 | $10.00 | None | $19.33 |
Browse Plan Formulary |
Fidelis Fully Integrated Dual Advantage (FIDA) (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | n/a | None | $19.19 |
Browse Plan Formulary |
GuildNet Gold Plus FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | 0% | None | $20.37 |
Browse Plan Formulary |
Healthfirst AbsoluteCare FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | 0% | None | $19.19 |
Browse Plan Formulary |
Integra FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | 0% | None | $17.74 |
Browse Plan Formulary |
RiverSpring FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | 0% | None | $12.66 |
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 |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $19.92 |
Browse Plan Formulary |
Touchstone Health Medicare Power (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $19.92 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (Regional PPO)
|
$0.00 |
$225* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$2.00 | $4.00 | None | $18.26 |
Browse Plan Formulary |
VNSNY CHOICE FIDA Complete (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | 0% | None | $18.13 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Enhanced (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $17.96 |
Browse Plan Formulary |
WellCare Advocate Complete FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | 0% | None | $18.82 |
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 |
1 |
Tier 1 |
25% | 25% | None | $19.19 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$28.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$2.00 | $5.00 | None | $18.10 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$30.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $18.28 |
Browse Plan Formulary |
LiveWell (HMO)
|
$32.90 |
$250 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$4.00 | $10.00 | None | $17.93 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Classic (HMO)
|
$34.10 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $17.96 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO SNP)
|
$35.40 |
$320* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $19.20 |
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 |
1 |
Tier 1 |
$0.00 | $0.00 | None | $19.19 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO SNP)
|
$36.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $19.19 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Preferred (HMO SNP)
|
$36.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $17.96 |
Browse Plan Formulary |
Affinity Medicare Solutions (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $19.22 |
Browse Plan Formulary |
Affinity Medicare Ultimate (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $19.22 |
Browse Plan Formulary |
ArchCare Advantage (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $19.46 |
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 | $17.93 |
Browse Plan Formulary |
CareWell (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $17.93 |
Browse Plan Formulary |
CenterLight Healthcare Direct Complete Plan (HMO SNP)
|
$36.90 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$4.00 | $12.00 | None | $20.50 |
Browse Plan Formulary |
EmblemHealth Dual Eligible (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$2.00 | $6.00 | None | $20.37 |
Browse Plan Formulary |
EmblemHealth Dual Eligible (PPO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$2.00 | $6.00 | None | $20.37 |
Browse Plan Formulary |
EmblemHealth MLTC PLUS (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$2.00 | $6.00 | None | $20.37 |
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 | $17.93 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
|
$36.90 |
$240* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $19.20 |
Browse Plan Formulary |
Touchstone Health Medicare Grand (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $19.92 |
Browse Plan Formulary |
Touchstone Health Medicare Prestige (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $19.92 |
Browse Plan Formulary |
Touchstone Health Medicare Total (HMO)
|
$36.90 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $19.92 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Maximum (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $17.96 |
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 |
VNSNY CHOICE Total (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $17.96 |
Browse Plan Formulary |
Affinity Medicare Passport Select (HMO)
|
$46.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $19.22 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$69.00 |
$240* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$2.00 | $4.00 | None | $18.43 |
Browse Plan Formulary |
Empire MediBlue Select (HMO)
|
$69.00 |
$273* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$5.00 | $10.00 | None | $19.28 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$94.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None | $19.09 |
Browse Plan Formulary |
GoldValue with Part D (HMO-POS)
|
$103.60 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$3.00 | $6.00 | None | $19.22 |
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 |
EmblemHealth Essential (HMO)
|
$122.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $20.59 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
|
$122.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $20.36 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
|
$122.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $20.18 |
Browse Plan Formulary |
Affinity Medicare Passport Elite (HMO)
|
$126.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $19.22 |
Browse Plan Formulary |
Preferred Gold with Part D (HMO-POS)
|
$167.40 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $19.22 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
|
$173.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $20.59 |
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 |
EmblemHealth VIP (HMO)
|
$173.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $20.36 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
|
$173.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $20.18 |
Browse Plan Formulary |
EmblemHealth Advantage (PPO)
|
$199.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $20.18 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$328.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $20.18 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$328.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $20.59 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$328.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $20.36 |
Browse Plan Formulary |