lamotrigine er 25 mg tablet (NDC: 49884056111)
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 Care (HMO)
![Email Prescription and/or Health Benefit details for Advantage Care (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$2.00 | $5.00 | None | $137.16 |
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 | $148.35 |
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. |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $127.45 |
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 | $113.09 |
Browse Plan Formulary |
AlphaCare Renew (HMO)
![Email Prescription and/or Health Benefit details for AlphaCare Renew (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 |
$15.00 | n/a | None | $137.16 |
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 |
AlphaCare Signature FIDA Plan (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for AlphaCare Signature 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% | n/a | None | $137.16 |
Browse Plan Formulary |
Amida Care True Life Plus (HMO)
![Email Prescription and/or Health Benefit details for Amida Care True Life Plus (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 |
$33.00 | $99.00 | None | $117.72 |
Browse Plan Formulary |
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 | $148.10 |
Browse Plan Formulary |
Easy Choice Diamond Rewards (HMO SNP)
![Email Prescription and/or Health Benefit details for Easy Choice Diamond Rewards (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$90.00 | $180.00 | None | $164.20 |
Browse Plan Formulary |
Easy Choice Rewards (HMO)
![Email Prescription and/or Health Benefit details for Easy Choice Rewards (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | None | $164.20 |
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 | $121.00 |
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)
![Email Prescription and/or Health Benefit details for EmblemHealth Essential (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 |
$10.00 | $30.00 | None | $118.08 |
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) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $123.68 |
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) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $121.59 |
Browse Plan Formulary |
FIDA Care Complete (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for FIDA Care Complete (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 | $137.16 |
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 | $148.35 |
Browse Plan Formulary |
Fidelis Medicare $0 Premium (HMO)
![Email Prescription and/or Health Benefit details for Fidelis Medicare $0 Premium (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 |
$18.00 | $36.00 | None | $148.35 |
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 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 | $121.00 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
![Email Prescription and/or Health Benefit details for Healthfirst 65 Plus Plan (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 |
$10.00 | $25.00 | None | $148.35 |
Browse Plan Formulary |
Healthfirst AbsoluteCare FIDA Plan (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for Healthfirst AbsoluteCare 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 | $148.35 |
Browse Plan Formulary |
Humana Gold Plus H3533-017 (HMO)
![Email Prescription and/or Health Benefit details for Humana Gold Plus H3533-017 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$320 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $125.69 |
Browse Plan Formulary |
ICS Community Care Plus FIDA MMP (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for ICS Community Care Plus FIDA MMP (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 | $137.16 |
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 | $127.50 |
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 |
Liberty Health Advantage Preferred Choice (HMO)
![Email Prescription and/or Health Benefit details for Liberty Health Advantage Preferred Choice (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $124.75 |
Browse Plan Formulary |
MetroPlus FIDA (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for MetroPlus 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 | $147.91 |
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 | $136.56 |
Browse Plan Formulary |
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 |
1 |
Tier 1 |
0% | 0% | None | $112.89 |
Browse Plan Formulary |
SWH Whole Health FIDA (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for SWH Whole Health 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 | $121.28 |
Browse Plan Formulary |
Touchstone Health Medicare Freedom (HMO-POS)
![Email Prescription and/or Health Benefit details for Touchstone Health Medicare Freedom (HMO-POS)](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 |
$10.00 | $25.00 | None | $124.75 |
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 |
Touchstone Health Medicare Power (HMO)
![Email Prescription and/or Health Benefit details for Touchstone Health Medicare Power (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 |
$10.00 | $25.00 | None | $124.75 |
Browse Plan Formulary |
VillageCareMAX Full Advantage FIDA (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for VillageCareMAX Full 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% | 0% | None | $137.16 |
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 | $122.02 |
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 | $121.87 |
Browse Plan Formulary |
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 | $148.35 |
Browse Plan Formulary |
Access Medicare Gold (HMO)
![Email Prescription and/or Health Benefit details for Access Medicare Gold (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$12.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$8.00 | $12.00 | None | $138.75 |
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 |
Humana Gold Plus SNP-DE H3533-004 (HMO SNP)
![Email Prescription and/or Health Benefit details for Humana Gold Plus SNP-DE H3533-004 (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$28.70 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $125.69 |
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 | $113.09 |
Browse Plan Formulary |
Fidelis Dual Advantage (HMO SNP)
![Email Prescription and/or Health Benefit details for Fidelis Dual Advantage (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$33.10 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$9.00 | $18.00 | None | $148.35 |
Browse Plan Formulary |
Healthfirst Increased Benefits Plan (HMO)
![Email Prescription and/or Health Benefit details for Healthfirst Increased Benefits Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$34.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $148.35 |
Browse Plan Formulary |
Healthfirst Mount Sinai Select (HMO)
![Email Prescription and/or Health Benefit details for Healthfirst Mount Sinai Select (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$34.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$0.00 | $0.00 | None | $148.35 |
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 | $121.87 |
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 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 | $148.35 |
Browse Plan Formulary |
Healthfirst AssuredCare (HMO SNP)
![Email Prescription and/or Health Benefit details for Healthfirst AssuredCare (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $148.35 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO SNP)
![Email Prescription and/or Health Benefit details for Healthfirst CompleteCare (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $148.35 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO SNP)
![Email Prescription and/or Health Benefit details for Healthfirst Life Improvement Plan (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $148.35 |
Browse Plan Formulary |
AlphaCare Resilience (HMO SNP)
![Email Prescription and/or Health Benefit details for AlphaCare Resilience (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.10 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | None | $137.16 |
Browse Plan Formulary |
AlphaCare Total (HMO SNP)
![Email Prescription and/or Health Benefit details for AlphaCare Total (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.20 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | n/a | None | $137.16 |
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 | $121.87 |
Browse Plan Formulary |
Access Medicare Pearl (HMO SNP)
![Email Prescription and/or Health Benefit details for Access Medicare Pearl (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 |
15% | 15% | None | $138.75 |
Browse Plan Formulary |
Access Medicare Platinum (HMO)
![Email Prescription and/or Health Benefit details for Access Medicare Platinum (HMO)](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 |
25% | 25% | None | $138.75 |
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 |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $127.45 |
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 |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $127.45 |
Browse Plan Formulary |
Amida Care Live Life Advantage (HMO SNP)
![Email Prescription and/or Health Benefit details for Amida Care Live Life Advantage (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 |
25% | 25% | None | $117.72 |
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 True Life Advantage (HMO SNP)
![Email Prescription and/or Health Benefit details for Amida Care True Life Advantage (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 |
15% | 15% | None | $117.72 |
Browse Plan Formulary |
ArchCare Advantage (HMO SNP)
![Email Prescription and/or Health Benefit details for ArchCare Advantage (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 | $136.80 |
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 | $113.09 |
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 | $113.09 |
Browse Plan Formulary |
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 | $149.12 |
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 | $121.00 |
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 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 | $121.00 |
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 | $121.00 |
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 | $113.09 |
Browse Plan Formulary |
Fidelis Medicaid Advantage Plus (HMO SNP)
![Email Prescription and/or Health Benefit details for Fidelis Medicaid Advantage 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 |
$12.00 | $24.00 | None | $148.35 |
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 | $148.35 |
Browse Plan Formulary |
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 | $120.63 |
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 |
Liberty Health Advantage Dual Power (HMO SNP)
![Email Prescription and/or Health Benefit details for Liberty Health Advantage Dual Power (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 |
15% | 15% | None | $124.75 |
Browse Plan Formulary |
MetroPlus Advantage Plan (HMO SNP)
![Email Prescription and/or Health Benefit details for MetroPlus Advantage 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 |
1 |
Tier 1 |
15% | 15% | None | $147.91 |
Browse Plan Formulary |
Senior Whole Health of New York NHC (HMO SNP)
![Email Prescription and/or Health Benefit details for Senior Whole Health of New York NHC (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 | $121.28 |
Browse Plan Formulary |
Touchstone Health Medicare Total (HMO)
![Email Prescription and/or Health Benefit details for Touchstone Health Medicare Total (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.90 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$7.00 | $17.50 | None | $124.75 |
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 | $121.87 |
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 | $121.87 |
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 |
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. |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $127.45 |
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) |
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $118.08 |
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) |
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $123.68 |
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) |
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $121.59 |
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) |
$96.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $124.03 |
Browse Plan Formulary |
MetroPlus Platinum (HMO)
![Email Prescription and/or Health Benefit details for MetroPlus Platinum (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$101.10 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $147.91 |
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 |
MetroPlus Select Plan (HMO SNP)
![Email Prescription and/or Health Benefit details for MetroPlus Select Plan (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$123.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $147.91 |
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. |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | None | $127.45 |
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) |
$233.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $121.59 |
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) |
$233.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $118.08 |
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) |
$233.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $30.00 | None | $123.68 |
Browse Plan Formulary |
MetroPlus Medicare Partnership in Care Plan (HMO SNP)
![Email Prescription and/or Health Benefit details for MetroPlus Medicare Partnership in Care Plan (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$244.20 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $147.91 |
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 |
HumanaChoice H5970-013 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice H5970-013 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$323.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $125.69 |
Browse Plan Formulary |