SAPHRIS 5 MG TAB SL BLK CHERRY (60 EA ) (NDC: 00456240560)
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 |
4 |
Non-Preferred Brand |
$93.00 | $269.00 | Q:60 /30Days | $1,008.38 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$330 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $290.00 | Q:60 /30Days | $1,008.38 |
Browse Plan Formulary |
Advantage Health NYC - SNP (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,033.59 |
Browse Plan Formulary |
Advantage Silver - NY City (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,033.59 |
Browse Plan Formulary |
Aetna Better Health FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | Q:60 /30Days | $1,023.79 |
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 |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$160 |
to be determined |
4 |
Non-Preferred Brand |
50% | 50% | Q:60 /30Days | $1,020.35 |
Browse Plan Formulary |
Affinity Medicare Passport Essentials NYC (HMO)
|
$0.00 |
$150 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:120 /30Days | $1,020.57 |
Browse Plan Formulary |
AgeWell New York FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | None | $1,012.00 |
Browse Plan Formulary |
AgeWell New York LiveWell (HMO)
|
$0.00 |
$275 |
to be determined |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | None | $1,012.00 |
Browse Plan Formulary |
AlphaCare Renew (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $1,017.17 |
Browse Plan Formulary |
AlphaCare Signature FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand Drugs |
0% | 0% | None | $1,017.17 |
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 Plus (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | Q:120 /30Days | $1,004.10 |
Browse Plan Formulary |
CenterLight Healthcare FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | P Q:60 /30Days | $1,009.61 |
Browse Plan Formulary |
Centers Plan for FIDA Care Complete (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | S Q:60 /30Days | $1,017.20 |
Browse Plan Formulary |
Centers Plan for Medicare Advantage Care (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Non-Preferred Brand |
$85.00 | $212.50 | S Q:60 /30Days | $1,019.10 |
Browse Plan Formulary |
Elderplan Diabetes Care (HMO SNP)
|
$0.00 |
$360 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None | $1,017.22 |
Browse Plan Formulary |
Elderplan FIDA Total Care (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | None | $1,017.22 |
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 |
Empire MediBlue Plus (HMO)
|
$0.00 |
$245 |
to be determined |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:120 /30Days | $1,003.84 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$245 |
to be determined |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:120 /30Days | $1,003.77 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$245 |
to be determined |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:120 /30Days | $999.64 |
Browse Plan Formulary |
Fidelis Fully Integrated Dual Advantage Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | n/a | Q:120 /30Days | $1,020.67 |
Browse Plan Formulary |
Fidelis Medicare $0 Premium (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | Q:120 /30Days | $1,020.90 |
Browse Plan Formulary |
GuildNet Gold Plus FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | Q:60 /30Days | $1,008.64 |
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 |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$95.00 | $238.00 | Q:120 /30Days | $993.61 |
Browse Plan Formulary |
Healthfirst AbsoluteCare FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | Q:120 /30Days | $993.55 |
Browse Plan Formulary |
Humana Gold Plus H3533-005 (HMO)
|
$0.00 |
$360 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $290.00 | P Q:60 /30Days | $1,006.96 |
Browse Plan Formulary |
ICS Community Care Plus FIDA MMP (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | S Q:60 /30Days | $1,017.45 |
Browse Plan Formulary |
Liberty Health Advantage Preferred Choice (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$85.00 | $255.00 | Q:120 /30Days | $1,039.78 |
Browse Plan Formulary |
MetroPlus FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | Q:120 /30Days | $1,024.42 |
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 |
North Shore-LIJ FIDA LiveWell (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | Q:120 /30Days | $1,020.62 |
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 | Q:60 /30Days | $1,000.26 |
Browse Plan Formulary |
RiverSpring FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | None | $979.33 |
Browse Plan Formulary |
SWH Whole Health FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | Q:120 /30Days | $1,003.76 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 1 (Regional PPO)
|
$0.00 |
$290 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $290.00 | Q:60 /30Days | $1,012.46 |
Browse Plan Formulary |
VillageCareMAX Full Advantage FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | S Q:60 /30Days | $1,017.45 |
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 FIDA Complete (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | S Q:60 /30Days | $1,003.76 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Enhanced (HMO)
|
$0.00 |
$360 |
to be determined |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S Q:60 /30Days | $1,004.14 |
Browse Plan Formulary |
WellCare Advocate Complete FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | Q:120 /30Days | $1,025.52 |
Browse Plan Formulary |
WellCare Choice (HMO-POS)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
48% | 48% | Q:120 /30Days | $1,025.53 |
Browse Plan Formulary |
Access Medicare Gold (HMO)
|
$10.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$75.00 | $112.50 | S Q:60 /30Days | $1,017.87 |
Browse Plan Formulary |
WellCare Rx (HMO)
|
$19.00 |
$360 |
to be determined |
4 |
Non-Preferred Brand |
50% | 50% | Q:120 /30Days | $1,025.53 |
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 H3533-021 (HMO)
|
$24.10 |
$360 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $290.00 | P Q:60 /30Days | $1,006.95 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
|
$29.00 |
$230 |
to be determined |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:60 /30Days | $1,008.38 |
Browse Plan Formulary |
Healthfirst AssuredCare (HMO SNP)
|
$30.80 |
$360 |
to be determined |
3 |
Tier 3 |
25% | 25% | Q:120 /30Days | $993.61 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
|
$32.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:60 /30Days | $1,012.22 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
|
$32.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:60 /30Days | $1,002.36 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
|
$32.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:60 /30Days | $1,004.89 |
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)
|
$32.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:60 /30Days | $1,007.87 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H3533-004 (HMO SNP)
|
$32.50 |
$165 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $290.00 | P Q:60 /30Days | $1,006.95 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$34.30 |
$360 |
to be determined |
4 |
Non-Preferred Brand |
50% | 50% | Q:120 /30Days | $1,025.53 |
Browse Plan Formulary |
Healthfirst Increased Benefits Plan (HMO)
|
$35.00 |
$360 |
to be determined |
3 |
Tier 3 |
25% | 25% | Q:120 /30Days | $993.61 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$35.90 |
$360 |
to be determined |
4 |
Tier 4 |
$0.00 | $0.00 | Q:60 /30Days | $1,013.16 |
Browse Plan Formulary |
MetroPlus Advantage Plan (HMO SNP)
|
$38.70 |
$360 |
to be determined |
1 |
Tier 1 |
15% | 15% | Q:120 /30Days | $993.96 |
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 |
Healthfirst CompleteCare (HMO SNP)
|
$39.00 |
$360 |
to be determined |
3 |
Tier 3 |
$0.00 | $0.00 | Q:120 /30Days | $993.56 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO SNP)
|
$39.00 |
$360 |
to be determined |
3 |
Tier 3 |
15% | 15% | Q:120 /30Days | $993.56 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 3 (Regional PPO)
|
$39.00 |
$150 |
to be determined |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:60 /30Days | $1,012.46 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$39.30 |
$360 |
to be determined |
4 |
Tier 4 |
25% | 25% | Q:60 /30Days | $1,013.41 |
Browse Plan Formulary |
Access Medicare Pearl (HMO SNP)
|
$39.70 |
$360 |
to be determined |
4 |
Tier 4 |
15% | 15% | S Q:60 /30Days | $1,017.87 |
Browse Plan Formulary |
Access Medicare Pearl Advantage (HMO SNP)
|
$39.70 |
$360 |
to be determined |
4 |
Tier 4 |
15% | 15% | S Q:60 /30Days | $1,017.87 |
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 |
Access Medicare Platinum (HMO)
|
$39.70 |
$360 |
to be determined |
4 |
Tier 4 |
25% | 25% | S Q:60 /30Days | $1,017.87 |
Browse Plan Formulary |
Access Medicare Platinum Advantage (HMO)
|
$39.70 |
$360 |
to be determined |
4 |
Tier 4 |
25% | 25% | S Q:60 /30Days | $1,017.87 |
Browse Plan Formulary |
Advantage Value One NY - Dual (HMO SNP)
|
$39.70 |
$0 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,046.38 |
Browse Plan Formulary |
Affinity Medicare Solutions (HMO SNP)
|
$39.70 |
$360 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:120 /30Days | $1,020.69 |
Browse Plan Formulary |
Affinity Medicare Ultimate (HMO SNP)
|
$39.70 |
$360 |
to be determined |
4 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:120 /30Days | $1,020.69 |
Browse Plan Formulary |
AgeWell New York BeWell (HMO SNP)
|
$39.70 |
$360 |
to be determined |
1 |
Tier 1 |
15% | 15% | None | $1,012.00 |
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 |
AgeWell New York CareWell (HMO SNP)
|
$39.70 |
$360 |
to be determined |
1 |
Tier 1 |
25% | 25% | None | $1,012.00 |
Browse Plan Formulary |
AgeWell New York FeelWell (HMO SNP)
|
$39.70 |
$360 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | None | $1,012.00 |
Browse Plan Formulary |
AlphaCare Resilience (HMO SNP)
|
$39.70 |
$360 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,017.17 |
Browse Plan Formulary |
AlphaCare Total (HMO SNP)
|
$39.70 |
$360 |
to be determined |
4 |
Tier 4 |
15% | 15% | None | $1,017.17 |
Browse Plan Formulary |
Amida Care Live Life Advantage (HMO SNP)
|
$39.70 |
$360 |
to be determined |
3 |
Preferred Brand |
25% | 25% | Q:120 /30Days | $1,004.10 |
Browse Plan Formulary |
Amida Care True Life Advantage (HMO SNP)
|
$39.70 |
$360 |
to be determined |
3 |
Tier 3 |
15% | 15% | Q:120 /30Days | $1,004.10 |
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 |
ArchCare Advantage (HMO SNP)
|
$39.70 |
$360 |
to be determined |
1 |
Tier 1 |
25% | 25% | Q:120 /30Days | $1,020.63 |
Browse Plan Formulary |
CenterLight Healthcare Direct Complete Plan (HMO SNP)
|
$39.70 |
$360 |
to be determined |
2 |
Brand |
25% | 25% | P Q:60 /30Days | $1,009.57 |
Browse Plan Formulary |
Centers Plan for Dual Coverage Care (HMO SNP)
|
$39.70 |
$360 |
to be determined |
3 |
Tier 3 |
15% | 15% | S Q:60 /30Days | $1,017.20 |
Browse Plan Formulary |
Centers Plan for Nursing Home Care (HMO SNP)
|
$39.70 |
$360 |
to be determined |
3 |
Tier 3 |
25% | 25% | S Q:60 /30Days | $1,019.10 |
Browse Plan Formulary |
Elderplan Advantage For Nursing Home Residents (HMO SNP)
|
$39.70 |
$360 |
to be determined |
1 |
Tier 1 |
25% | 25% | None | $1,017.23 |
Browse Plan Formulary |
Elderplan Extra Help (HMO)
|
$39.70 |
$360 |
to be determined |
1 |
Tier 1 |
25% | 25% | None | $1,017.22 |
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 |
Elderplan For Medicaid Beneficiaries (HMO SNP)
|
$39.70 |
$360 |
to be determined |
1 |
Tier 1 |
15% | 15% | None | $1,017.22 |
Browse Plan Formulary |
Elderplan Plus Long Term Care (HMO SNP)
|
$39.70 |
$360 |
to be determined |
1 |
Tier 1 |
15% | 15% | None | $1,017.22 |
Browse Plan Formulary |
EmblemHealth Dual Eligible (HMO SNP)
|
$39.70 |
$360 |
to be determined |
4 |
Non-Preferred Brand |
30% | 30% | Q:60 /30Days | $1,008.64 |
Browse Plan Formulary |
EmblemHealth Dual Eligible (PPO SNP)
|
$39.70 |
$360 |
to be determined |
4 |
Non-Preferred Brand |
30% | 30% | Q:60 /30Days | $1,008.64 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage (HMO SNP)
|
$39.70 |
$360 |
to be determined |
4 |
Non-Preferred Brand |
$94.00 | $282.00 | Q:120 /30Days | $1,008.19 |
Browse Plan Formulary |
Fidelis Dual Advantage (HMO SNP)
|
$39.70 |
$360 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | Q:120 /30Days | $1,020.94 |
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 |
Fidelis Dual Advantage Flex (HMO SNP)
|
$39.70 |
$360 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | Q:120 /30Days | $1,020.90 |
Browse Plan Formulary |
Fidelis Medicaid Advantage Plus (HMO SNP)
|
$39.70 |
$360 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | Q:120 /30Days | $1,020.62 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
|
$39.70 |
$250 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | Q:120 /30Days | $1,020.90 |
Browse Plan Formulary |
GuildNet Gold (HMO SNP)
|
$39.70 |
$360 |
to be determined |
4 |
Non-Preferred Brand |
25% | 25% | Q:60 /30Days | $1,008.81 |
Browse Plan Formulary |
Liberty Health Advantage Dual Power (HMO SNP)
|
$39.70 |
$360 |
to be determined |
4 |
Tier 4 |
15% | 15% | Q:120 /30Days | $1,039.78 |
Browse Plan Formulary |
RiverSpring Star (HMO SNP)
|
$39.70 |
$360 |
to be determined |
1 |
Tier 1 |
25% | 25% | None | $979.33 |
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 |
Senior Whole Health of New York NHC (HMO SNP)
|
$39.70 |
$360 |
to be determined |
1 |
Tier 1 |
$0.00 | $0.00 | Q:120 /30Days | $1,003.45 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Classic (HMO)
|
$39.70 |
$360 |
to be determined |
4 |
Tier 4 |
25% | 25% | S Q:60 /30Days | $1,004.14 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Preferred (HMO SNP)
|
$39.70 |
$360 |
to be determined |
4 |
Tier 4 |
15% | 15% | S Q:60 /30Days | $1,004.14 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO SNP)
|
$39.70 |
$360 |
to be determined |
4 |
Tier 4 |
$0.00 | $0.00 | S Q:60 /30Days | $1,003.76 |
Browse Plan Formulary |
Affinity Medicare Passport Select (HMO)
|
$41.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:120 /30Days | $1,020.69 |
Browse Plan Formulary |
AARP MedicareComplete Plan 3 (HMO)
|
$69.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:60 /30Days | $1,008.38 |
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 MedicareComplete Choice Plan 4 (Regional PPO)
|
$69.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:60 /30Days | $1,012.46 |
Browse Plan Formulary |
Advantage Platinum Plus NY (HMO)
|
$85.00 |
$0 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,046.38 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$96.00 |
$150 |
to be determined |
4 |
Non-Preferred Brand |
50% | 50% | Q:60 /30Days | $1,020.58 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Ultra (HMO-POS)
|
$96.40 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S Q:60 /30Days | $1,004.14 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
|
$103.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:60 /30Days | $1,007.87 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
|
$103.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:60 /30Days | $1,012.22 |
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 VIP (HMO)
|
$103.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:60 /30Days | $1,002.36 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
|
$103.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:60 /30Days | $1,004.89 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Maximum (HMO SNP)
|
$115.80 |
$360 |
to be determined |
4 |
Tier 4 |
$0.00 | $0.00 | S Q:60 /30Days | $1,003.76 |
Browse Plan Formulary |
MetroPlus Platinum (HMO)
|
$184.30 |
$360 |
to be determined |
1 |
Tier 1 |
25% | 25% | Q:120 /30Days | $993.96 |
Browse Plan Formulary |
Aetna Medicare Connect Plus (PPO)
|
$188.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
50% | 50% | Q:60 /30Days | $1,023.93 |
Browse Plan Formulary |
EmblemHealth Advantage (PPO)
|
$223.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:60 /30Days | $1,013.84 |
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)
|
$306.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:60 /30Days | $1,012.22 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$306.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:60 /30Days | $1,002.36 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$306.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:60 /30Days | $1,004.89 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$306.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:60 /30Days | $1,007.87 |
Browse Plan Formulary |