AMIFOSTINE 50mg/mL 3 VIAL, SINGLE-USE per CARTON / 10 mL in 1 VIAL, SINGLE-USE (3 VIAL, SINGLE-USE in 1 C ) (NDC: 47335058142)
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% | None | $1,170.28 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$330 | to be determined | 5 |
Specialty Tier |
25% | 25% | None | $1,170.28 |
Browse Plan Formulary |
Advantage Health NYC - SNP (HMO SNP)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,277.12 |
Browse Plan Formulary |
Advantage Silver - NY City (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,277.12 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$200 | to be determined | 5 |
Specialty Tier |
28% | n/a | None | $1,387.10 |
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 |
Affinity Medicare Passport Essentials NYC (HMO)
|
$0.00 |
$150 | to be determined | 5 |
Specialty Tier |
29% | n/a | P | $1,439.70 |
Browse Plan Formulary |
Amida Care True Life Plus (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Specialty Tier |
33% | 33% | None | $1,384.92 |
Browse Plan Formulary |
CenterLight Healthcare FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Generic Drugs |
0% | 0% | P | $1,356.95 |
Browse Plan Formulary |
Centers Plan for FIDA Care Complete (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Generic Drugs |
0% | 0% | None | $1,324.14 |
Browse Plan Formulary |
Centers Plan for Medicare Advantage Care (HMO)
|
$0.00 |
$0 | to be determined | 1 |
Generic |
$2.00 | $5.00 | None | $1,324.14 |
Browse Plan Formulary |
Elderplan Diabetes Care (HMO SNP)
|
$0.00 |
$360 | to be determined | 4 |
Non-Preferred Brand |
$100.00 | $250.00 | None | $1,271.87 |
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 |
Elderplan FIDA Total Care (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Generic Drugs |
0% | 0% | None | $1,271.87 |
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 | $1,272.09 |
Browse Plan Formulary |
Fidelis Medicare $0 Premium (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | P | $1,272.09 |
Browse Plan Formulary |
GuildNet Gold Plus FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Brand Drugs |
0% | 0% | P | $1,383.68 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | 33% | P | $1,271.67 |
Browse Plan Formulary |
Healthfirst AbsoluteCare FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Brand Drugs |
0% | 0% | P | $1,271.66 |
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 |
Humana Gold Plus H3533-007 (HMO)
|
$0.00 |
$360 | to be determined | 5 |
Specialty Tier |
25% | n/a | P | $1,768.96 |
Browse Plan Formulary |
Liberty Health Advantage Preferred Choice (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | P | $1,272.81 |
Browse Plan Formulary |
North Shore-LIJ FIDA LiveWell (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Brand Drugs |
0% | 0% | P | $1,272.08 |
Browse Plan Formulary |
PHP Care Complete FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Tier 1 |
0% | n/a | P | $1,272.26 |
Browse Plan Formulary |
RiverSpring FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Generic Drugs |
0% | 0% | None | $1,134.44 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 1 (Regional PPO)
|
$0.00 |
$290 | to be determined | 5 |
Specialty Tier |
26% | 26% | None | $1,168.98 |
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 |
VNSNY CHOICE FIDA Complete (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Generic Drugs |
0% | 0% | None | $1,238.07 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Enhanced (HMO)
|
$0.00 |
$360 | to be determined | 2 |
Generic |
$9.00 | $27.00 | None | $1,238.07 |
Browse Plan Formulary |
WellCare Advocate Complete FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Brand Drugs |
0% | 0% | P | $1,271.59 |
Browse Plan Formulary |
WellCare Choice (HMO-POS)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | P | $1,506.21 |
Browse Plan Formulary |
WellCare Rx (HMO)
|
$19.00 |
$360 | to be determined | 5 |
Specialty Tier |
25% | n/a | P | $1,506.21 |
Browse Plan Formulary |
Humana Gold Plus H3533-021 (HMO)
|
$24.10 |
$360 | to be determined | 5 |
Specialty Tier |
25% | n/a | P | $1,768.96 |
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 |
AARP MedicareComplete Plan 1 (HMO)
|
$29.00 |
$230 | to be determined | 5 |
Specialty Tier |
27% | 27% | None | $1,170.28 |
Browse Plan Formulary |
Healthfirst AssuredCare (HMO SNP)
|
$30.80 |
$360 | to be determined | 4 |
Tier 4 |
25% | 25% | P | $1,271.67 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
|
$32.00 |
$0 | to be determined | 5 |
Specialty Tier |
25% | 25% | P | $1,383.68 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
|
$32.00 |
$0 | to be determined | 5 |
Specialty Tier |
25% | 25% | P | $1,383.68 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
|
$32.00 |
$0 | to be determined | 5 |
Specialty Tier |
25% | 25% | P | $1,383.68 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
|
$32.00 |
$0 | to be determined | 5 |
Specialty Tier |
25% | 25% | P | $1,383.68 |
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)
|
$32.50 |
$165 | to be determined | 5 |
Specialty Tier |
29% | n/a | P | $1,768.96 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$34.30 |
$360 | to be determined | 5 |
Specialty Tier |
25% | n/a | P | $1,271.59 |
Browse Plan Formulary |
Healthfirst Increased Benefits Plan (HMO)
|
$35.00 |
$360 | to be determined | 4 |
Tier 4 |
25% | 25% | P | $1,271.67 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$35.90 |
$360 | to be determined | 5 |
Tier 5 |
$0.00 | $0.00 | None | $1,168.98 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO SNP)
|
$39.00 |
$360 | to be determined | 4 |
Tier 4 |
$0.00 | $0.00 | P | $1,271.67 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO SNP)
|
$39.00 |
$360 | to be determined | 4 |
Tier 4 |
15% | 15% | P | $1,271.67 |
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 3 (Regional PPO)
|
$39.00 |
$150 | to be determined | 5 |
Specialty Tier |
29% | 29% | None | $1,168.98 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$39.30 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | None | $1,168.98 |
Browse Plan Formulary |
Advantage Value One NY - Dual (HMO SNP)
|
$39.70 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,272.82 |
Browse Plan Formulary |
Affinity Medicare Solutions (HMO SNP)
|
$39.70 |
$360 | to be determined | 5 |
Specialty Tier |
25% | n/a | P | $1,272.09 |
Browse Plan Formulary |
Affinity Medicare Ultimate (HMO SNP)
|
$39.70 |
$360 | to be determined | 5 |
Specialty Tier |
25% | n/a | P | $1,272.09 |
Browse Plan Formulary |
Amida Care Live Life Advantage (HMO SNP)
|
$39.70 |
$360 | to be determined | 5 |
Specialty Tier |
25% | 25% | None | $1,384.92 |
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)
|
$39.70 |
$360 | to be determined | 5 |
Tier 5 |
15% | 15% | None | $1,384.92 |
Browse Plan Formulary |
ArchCare Advantage (HMO SNP)
|
$39.70 |
$360 | to be determined | 1 |
Tier 1 |
25% | 25% | P | $1,439.70 |
Browse Plan Formulary |
CenterLight Healthcare Direct Complete Plan (HMO SNP)
|
$39.70 |
$360* | to be determined | 1* |
Generic |
$9.50 | $28.50 | P | $1,356.95 |
Browse Plan Formulary |
Centers Plan for Dual Coverage Care (HMO SNP)
|
$39.70 |
$360 | to be determined | 1 |
Tier 1 |
15% | 15% | None | $1,323.24 |
Browse Plan Formulary |
Centers Plan for Nursing Home Care (HMO SNP)
|
$39.70 |
$360 | to be determined | 1 |
Tier 1 |
25% | 25% | None | $1,323.24 |
Browse Plan Formulary |
Elderplan Advantage For Nursing Home Residents (HMO SNP)
|
$39.70 |
$360 | to be determined | 1 |
Tier 1 |
25% | 25% | None | $1,271.87 |
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 |
Elderplan Plus Long Term Care (HMO SNP)
|
$39.70 |
$360 | to be determined | 1 |
Tier 1 |
15% | 15% | None | $1,271.87 |
Browse Plan Formulary |
EmblemHealth Dual Eligible (HMO SNP)
|
$39.70 |
$360 | to be determined | 5 |
Specialty Tier |
25% | 25% | P | $1,383.68 |
Browse Plan Formulary |
EmblemHealth Dual Eligible (PPO SNP)
|
$39.70 |
$360 | to be determined | 5 |
Specialty Tier |
25% | 25% | P | $1,383.68 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage (HMO SNP)
|
$39.70 |
$360 | to be determined | 5 |
Specialty Tier |
25% | n/a | P | $1,384.35 |
Browse Plan Formulary |
Fidelis Dual Advantage (HMO SNP)
|
$39.70 |
$360 | to be determined | 5 |
Specialty Tier |
25% | n/a | P | $1,514.65 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO SNP)
|
$39.70 |
$360 | to be determined | 5 |
Specialty Tier |
25% | n/a | P | $1,272.09 |
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 Medicaid Advantage Plus (HMO SNP)
|
$39.70 |
$360 | to be determined | 5 |
Specialty Tier |
25% | n/a | P | $1,514.65 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
|
$39.70 |
$250 | to be determined | 5 |
Specialty Tier |
27% | n/a | P | $1,272.09 |
Browse Plan Formulary |
GuildNet Gold (HMO SNP)
|
$39.70 |
$360 | to be determined | 5 |
Specialty Tier |
25% | 25% | P | $1,383.68 |
Browse Plan Formulary |
Liberty Health Advantage Dual Power (HMO SNP)
|
$39.70 |
$360 | to be determined | 5 |
Tier 5 |
15% | 15% | P | $1,272.81 |
Browse Plan Formulary |
RiverSpring Star (HMO SNP)
|
$39.70 |
$360 | to be determined | 1 |
Tier 1 |
25% | 25% | None | $1,134.44 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Classic (HMO)
|
$39.70 |
$360 | to be determined | 2 |
Tier 2 |
25% | 25% | None | $1,238.07 |
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)
|
$39.70 |
$360 | to be determined | 2 |
Tier 2 |
15% | 15% | None | $1,238.07 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO SNP)
|
$39.70 |
$360 | to be determined | 2 |
Tier 2 |
$0.00 | $0.00 | None | $1,238.07 |
Browse Plan Formulary |
Affinity Medicare Passport Select (HMO)
|
$41.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | P | $1,272.09 |
Browse Plan Formulary |
AARP MedicareComplete Plan 3 (HMO)
|
$69.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | 33% | None | $1,170.28 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$69.00 |
$200 | to be determined | 5 |
Specialty Tier |
28% | n/a | None | $1,387.10 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 4 (Regional PPO)
|
$69.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | 33% | None | $1,168.98 |
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 |
Advantage Platinum Plus NY (HMO)
|
$85.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,272.82 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$96.00 |
$150 | to be determined | 5 |
Specialty Tier |
29% | n/a | None | $1,387.10 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Ultra (HMO-POS)
|
$96.40 |
$0 | to be determined | 2 |
Generic |
$9.00 | $27.00 | None | $1,238.07 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
|
$103.00 |
$0 | to be determined | 5 |
Specialty Tier |
25% | 25% | P | $1,383.68 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
|
$103.00 |
$0 | to be determined | 5 |
Specialty Tier |
25% | 25% | P | $1,383.68 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
|
$103.00 |
$0 | to be determined | 5 |
Specialty Tier |
25% | 25% | P | $1,383.68 |
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 | 5 |
Specialty Tier |
25% | 25% | P | $1,383.68 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Maximum (HMO SNP)
|
$115.80 |
$360 | to be determined | 2 |
Tier 2 |
$0.00 | $0.00 | None | $1,238.07 |
Browse Plan Formulary |
Aetna Medicare Connect Plus (PPO)
|
$188.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $1,354.89 |
Browse Plan Formulary |
EmblemHealth Advantage (PPO)
|
$260.00 |
$0 | to be determined | 5 |
Specialty Tier |
25% | 25% | P | $1,383.68 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$306.00 |
$0 | to be determined | 5 |
Specialty Tier |
25% | 25% | P | $1,383.68 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$306.00 |
$0 | to be determined | 5 |
Specialty Tier |
25% | 25% | P | $1,383.68 |
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 | 5 |
Specialty Tier |
25% | 25% | P | $1,383.68 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$306.00 |
$0 | to be determined | 5 |
Specialty Tier |
25% | 25% | P | $1,383.68 |
Browse Plan Formulary |