SANDOSTATIN LAR DEPOT 20 MG KT (1 EA ) (NDC: 00078064781)
2016 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 |
$245 |
to be determined |
5 |
Specialty Tier |
27% | 27% | P | $3,625.90 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$330 |
to be determined |
5 |
Specialty Tier |
25% | 25% | P | $3,625.90 |
Browse Plan Formulary |
Affinity Medicare Passport Essentials NYC (HMO)
|
$0.00 |
$150 |
to be determined |
5 |
Specialty Tier |
29% | n/a | P | $3,766.49 |
Browse Plan Formulary |
AgeWell New York FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | None | $3,543.63 |
Browse Plan Formulary |
AgeWell New York LiveWell (HMO)
|
$0.00 |
$275 |
to be determined |
5 |
Specialty Tier |
25% | 25% | None | $3,543.63 |
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 |
AlphaCare Renew (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | P | $3,570.25 |
Browse Plan Formulary |
AlphaCare Signature FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand Drugs |
0% | 0% | P | $3,570.25 |
Browse Plan Formulary |
Amida Care True Life Plus (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Specialty Tier |
33% | 33% | None | $3,649.47 |
Browse Plan Formulary |
Centers Plan for FIDA Care Complete (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | None | $3,637.72 |
Browse Plan Formulary |
Centers Plan for Medicare Advantage Care (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Specialty Tier |
33% | 33% | None | $3,637.72 |
Browse Plan Formulary |
Elderplan Diabetes Care (HMO SNP)
|
$0.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | 25% | None | $3,761.95 |
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 FIDA Total Care (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | None | $3,758.81 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
25% | 25% | P | $3,649.18 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
25% | 25% | P | $3,649.18 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
25% | 25% | P | $3,649.18 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
25% | 25% | P | $3,649.18 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$245 |
to be determined |
5 |
Specialty Tier |
27% | n/a | P | $3,650.40 |
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 Plus (HMO)
|
$0.00 |
$245 |
to be determined |
5 |
Specialty Tier |
27% | n/a | P | $3,650.40 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$245 |
to be determined |
5 |
Specialty Tier |
27% | n/a | P | $3,650.40 |
Browse Plan Formulary |
Fidelis Fully Integrated Dual Advantage Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | n/a | P | $3,880.15 |
Browse Plan Formulary |
Fidelis Medicare $0 Premium (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | P | $3,880.15 |
Browse Plan Formulary |
GuildNet Gold Plus FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | P | $3,649.18 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | P | $3,767.91 |
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 |
Healthfirst AbsoluteCare FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | P | $3,764.04 |
Browse Plan Formulary |
Humana Gold Plus H3533-017 (HMO)
|
$0.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | P | $3,596.63 |
Browse Plan Formulary |
ICS Community Care Plus FIDA MMP (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | None | $3,630.89 |
Browse Plan Formulary |
Liberty Health Advantage Preferred Choice (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | P | $3,670.02 |
Browse Plan Formulary |
MetroPlus FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | P | $3,742.56 |
Browse Plan Formulary |
PHP Care Complete FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Tier 2 |
0% | n/a | P | $3,527.47 |
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)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | P | $3,403.90 |
Browse Plan Formulary |
SWH Whole Health FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | None | $3,650.81 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 1 (Regional PPO)
|
$0.00 |
$290 |
to be determined |
5 |
Specialty Tier |
26% | 26% | P | $3,625.90 |
Browse Plan Formulary |
VillageCareMAX Full Advantage FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | None | $3,637.65 |
Browse Plan Formulary |
VNSNY CHOICE FIDA Complete (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | None | $3,673.94 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Enhanced (HMO)
|
$0.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | 25% | None | $3,673.94 |
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 |
WellCare Advocate Complete FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | P | $3,838.57 |
Browse Plan Formulary |
Access Medicare Gold (HMO)
|
$10.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | None | $3,633.12 |
Browse Plan Formulary |
Humana Gold Plus H3533-021 (HMO)
|
$24.10 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | P | $3,596.63 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
|
$29.00 |
$230 |
to be determined |
5 |
Specialty Tier |
27% | 27% | P | $3,625.90 |
Browse Plan Formulary |
Healthfirst AssuredCare (HMO SNP)
|
$30.80 |
$360 |
to be determined |
4 |
Tier 4 |
25% | 25% | P | $3,767.91 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H3533-004 (HMO SNP)
|
$32.50 |
$165 |
to be determined |
5 |
Specialty Tier |
29% | n/a | P | $3,596.63 |
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 |
Healthfirst Increased Benefits Plan (HMO)
|
$35.00 |
$360 |
to be determined |
4 |
Tier 4 |
25% | 25% | P | $3,767.91 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$35.90 |
$360 |
to be determined |
5 |
Tier 5 |
$0.00 | $0.00 | P | $3,625.90 |
Browse Plan Formulary |
MetroPlus Advantage Plan (HMO SNP)
|
$38.70 |
$360 |
to be determined |
1 |
Tier 1 |
15% | 15% | P | $3,769.13 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO SNP)
|
$39.00 |
$360 |
to be determined |
4 |
Tier 4 |
$0.00 | $0.00 | P | $3,767.91 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO SNP)
|
$39.00 |
$360 |
to be determined |
4 |
Tier 4 |
15% | 15% | P | $3,767.91 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 3 (Regional PPO)
|
$39.00 |
$150 |
to be determined |
5 |
Specialty Tier |
29% | 29% | P | $3,625.90 |
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 |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$39.30 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | P | $3,625.90 |
Browse Plan Formulary |
Access Medicare Pearl (HMO SNP)
|
$39.70 |
$360 |
to be determined |
5 |
Tier 5 |
15% | 15% | None | $3,633.12 |
Browse Plan Formulary |
Access Medicare Pearl Advantage (HMO SNP)
|
$39.70 |
$360 |
to be determined |
5 |
Tier 5 |
15% | 15% | None | $3,633.12 |
Browse Plan Formulary |
Access Medicare Platinum (HMO)
|
$39.70 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $3,633.12 |
Browse Plan Formulary |
Access Medicare Platinum Advantage (HMO)
|
$39.70 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $3,633.12 |
Browse Plan Formulary |
Affinity Medicare Solutions (HMO SNP)
|
$39.70 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | P | $3,766.49 |
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 |
Affinity Medicare Ultimate (HMO SNP)
|
$39.70 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | P | $3,766.49 |
Browse Plan Formulary |
AgeWell New York BeWell (HMO SNP)
|
$39.70 |
$360 |
to be determined |
1 |
Tier 1 |
15% | 15% | None | $3,543.63 |
Browse Plan Formulary |
AgeWell New York CareWell (HMO SNP)
|
$39.70 |
$360 |
to be determined |
1 |
Tier 1 |
25% | 25% | None | $3,543.63 |
Browse Plan Formulary |
AgeWell New York FeelWell (HMO SNP)
|
$39.70 |
$360 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | None | $3,543.63 |
Browse Plan Formulary |
AlphaCare Resilience (HMO SNP)
|
$39.70 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | P | $3,570.25 |
Browse Plan Formulary |
AlphaCare Total (HMO SNP)
|
$39.70 |
$360 |
to be determined |
5 |
Tier 5 |
15% | 15% | P | $3,570.25 |
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)
|
$39.70 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | 25% | None | $3,649.47 |
Browse Plan Formulary |
Amida Care True Life Advantage (HMO SNP)
|
$39.70 |
$360 |
to be determined |
5 |
Tier 5 |
15% | 15% | None | $3,649.47 |
Browse Plan Formulary |
ArchCare Advantage (HMO SNP)
|
$39.70 |
$360 |
to be determined |
1 |
Tier 1 |
25% | 25% | P | $3,766.49 |
Browse Plan Formulary |
Centers Plan for Dual Coverage Care (HMO SNP)
|
$39.70 |
$360 |
to be determined |
4 |
Tier 4 |
15% | 15% | None | $3,641.59 |
Browse Plan Formulary |
Centers Plan for Nursing Home Care (HMO SNP)
|
$39.70 |
$360 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $3,641.59 |
Browse Plan Formulary |
Elderplan Advantage For Nursing Home Residents (HMO SNP)
|
$39.70 |
$360 |
to be determined |
1 |
Tier 1 |
25% | 25% | None | $3,761.95 |
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 Extra Help (HMO)
|
$39.70 |
$360 |
to be determined |
1 |
Tier 1 |
25% | 25% | None | $3,761.95 |
Browse Plan Formulary |
Elderplan For Medicaid Beneficiaries (HMO SNP)
|
$39.70 |
$360 |
to be determined |
1 |
Tier 1 |
15% | 15% | None | $3,761.95 |
Browse Plan Formulary |
Elderplan Plus Long Term Care (HMO SNP)
|
$39.70 |
$360 |
to be determined |
1 |
Tier 1 |
15% | 15% | None | $3,761.95 |
Browse Plan Formulary |
EmblemHealth Dual Eligible (HMO SNP)
|
$39.70 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | 25% | P | $3,649.18 |
Browse Plan Formulary |
EmblemHealth Dual Eligible (PPO SNP)
|
$39.70 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | 25% | P | $3,649.18 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage (HMO SNP)
|
$39.70 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | P | $3,650.40 |
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 (HMO SNP)
|
$39.70 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | P | $3,880.15 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO SNP)
|
$39.70 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | P | $3,880.15 |
Browse Plan Formulary |
Fidelis Medicaid Advantage Plus (HMO SNP)
|
$39.70 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | P | $3,880.15 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
|
$39.70 |
$250 |
to be determined |
5 |
Specialty Tier |
27% | n/a | P | $3,880.15 |
Browse Plan Formulary |
GuildNet Gold (HMO SNP)
|
$39.70 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | 25% | P | $3,649.18 |
Browse Plan Formulary |
Liberty Health Advantage Dual Power (HMO SNP)
|
$39.70 |
$360 |
to be determined |
5 |
Tier 5 |
15% | 15% | P | $3,656.01 |
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 Star (HMO SNP)
|
$39.70 |
$360 |
to be determined |
1 |
Tier 1 |
25% | 25% | P | $3,403.90 |
Browse Plan Formulary |
Senior Whole Health of New York NHC (HMO SNP)
|
$39.70 |
$360 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | None | $3,648.99 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Classic (HMO)
|
$39.70 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $3,673.94 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Preferred (HMO SNP)
|
$39.70 |
$360 |
to be determined |
5 |
Tier 5 |
15% | 15% | None | $3,673.94 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO SNP)
|
$39.70 |
$360 |
to be determined |
5 |
Tier 5 |
$0.00 | $0.00 | None | $3,673.94 |
Browse Plan Formulary |
Affinity Medicare Passport Select (HMO)
|
$41.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | P | $3,766.49 |
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 |
AARP MedicareComplete Plan 3 (HMO)
|
$69.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | P | $3,625.90 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 4 (Regional PPO)
|
$69.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | P | $3,625.90 |
Browse Plan Formulary |
Empire MediBlue Access (PPO)
|
$70.00 |
$240 |
to be determined |
5 |
Specialty Tier |
27% | n/a | P | $3,650.40 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
|
$78.00 |
$0 |
to be determined |
5 |
Specialty Tier |
25% | 25% | P | $3,649.18 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
|
$78.00 |
$0 |
to be determined |
5 |
Specialty Tier |
25% | 25% | P | $3,649.18 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
|
$78.00 |
$0 |
to be determined |
5 |
Specialty Tier |
25% | 25% | P | $3,649.18 |
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)
|
$78.00 |
$0 |
to be determined |
5 |
Specialty Tier |
25% | 25% | P | $3,649.18 |
Browse Plan Formulary |
EmblemHealth Advantage (PPO)
|
$88.00 |
$0 |
to be determined |
5 |
Specialty Tier |
25% | 25% | P | $3,649.18 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Ultra (HMO-POS)
|
$96.40 |
$0 |
to be determined |
5 |
Specialty Tier |
25% | 25% | None | $3,673.94 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Maximum (HMO SNP)
|
$115.80 |
$360 |
to be determined |
5 |
Tier 5 |
$0.00 | $0.00 | None | $3,673.94 |
Browse Plan Formulary |
MetroPlus Platinum (HMO)
|
$184.30 |
$360 |
to be determined |
1 |
Tier 1 |
25% | 25% | P | $3,769.13 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$290.00 |
$0 |
to be determined |
5 |
Specialty Tier |
25% | 25% | P | $3,649.18 |
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)
|
$290.00 |
$0 |
to be determined |
5 |
Specialty Tier |
25% | 25% | P | $3,649.18 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$290.00 |
$0 |
to be determined |
5 |
Specialty Tier |
25% | 25% | P | $3,649.18 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$290.00 |
$0 |
to be determined |
5 |
Specialty Tier |
25% | 25% | P | $3,649.18 |
Browse Plan Formulary |