LATUDA 120 MG TABLET (30 EA ) (NDC: 63402031230)
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 |
Advantage Health NY - SNP (HMO SNP)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | Q:30 /30Days | $1,441.86 |
Browse Plan Formulary |
Advantage Silver - NY (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | Q:30 /30Days | $1,441.86 |
Browse Plan Formulary |
Aetna Better Health FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Brand Drugs |
0% | 0% | Q:30 /30Days | $1,400.27 |
Browse Plan Formulary |
Affinity Medicare Passport Essentials (HMO)
|
$0.00 |
$250 | to be determined | 4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:30 /30Days | $1,396.08 |
Browse Plan Formulary |
AgeWell New York FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Brand Drugs |
0% | 0% | None | $1,389.34 |
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 LiveWell (HMO)
|
$0.00 |
$275 | to be determined | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $1,389.34 |
Browse Plan Formulary |
CenterLight Healthcare FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Brand Drugs |
0% | 0% | P Q:30 /30Days | $1,382.00 |
Browse Plan Formulary |
Elderplan Diabetes Care (HMO SNP)
|
$0.00 |
$360 | to be determined | 3 |
Preferred Brand |
$47.00 | $117.50 | Q:90 /90Days | $1,391.06 |
Browse Plan Formulary |
Elderplan FIDA Total Care (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Brand Drugs |
0% | 0% | Q:90 /90Days | $1,391.05 |
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:30 /30Days | $1,395.74 |
Browse Plan Formulary |
Fidelis Medicare $0 Premium (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Brand |
$100.00 | $200.00 | Q:30 /30Days | $1,396.05 |
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)
|
$0.00 |
$0 | to be determined | 2 |
Brand Drugs |
0% | 0% | None | $1,378.38 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Brand |
$95.00 | $238.00 | Q:30 /30Days | $1,358.95 |
Browse Plan Formulary |
Healthfirst AbsoluteCare FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Brand Drugs |
0% | 0% | Q:30 /30Days | $1,358.39 |
Browse Plan Formulary |
Liberty Health Advantage Preferred Choice (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | Q:30 /30Days | $1,421.63 |
Browse Plan Formulary |
North Shore-LIJ FIDA LiveWell (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Brand Drugs |
0% | 0% | Q:30 /30Days | $1,395.73 |
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:30 /30Days | $1,374.14 |
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% | None | $1,416.97 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 1 (Regional PPO)
|
$0.00 |
$290 | to be determined | 5 |
Specialty Tier |
26% | 26% | Q:30 /30Days | $1,386.10 |
Browse Plan Formulary |
VNSNY CHOICE FIDA Complete (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Brand Drugs |
0% | 0% | None | $1,374.68 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Enhanced (HMO)
|
$0.00 |
$360 | to be determined | 4 |
Non-Preferred Brand |
$95.00 | $285.00 | None | $1,375.03 |
Browse Plan Formulary |
WellCare Advocate Complete FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Brand Drugs |
0% | 0% | Q:30 /30Days | $1,402.49 |
Browse Plan Formulary |
WellCare Choice (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Brand |
48% | 48% | Q:30 /30Days | $1,402.50 |
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 |
Humana Gold Plus SNP-DE H3533-022 (HMO SNP)
|
$29.70 |
$360 | to be determined | 5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,377.36 |
Browse Plan Formulary |
Healthfirst AssuredCare (HMO SNP)
|
$30.80 |
$360 | to be determined | 3 |
Tier 3 |
25% | 25% | Q:30 /30Days | $1,358.95 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
|
$32.00 |
$0 | to be determined | 4 |
Non-Preferred Brand |
$100.00 | $300.00 | None | $1,376.82 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
|
$32.00 |
$0 | to be determined | 4 |
Non-Preferred Brand |
$100.00 | $300.00 | None | $1,379.69 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
|
$32.00 |
$0 | to be determined | 4 |
Non-Preferred Brand |
$100.00 | $300.00 | None | $1,374.27 |
Browse Plan Formulary |
EmblemHealth Essential (HMO)
|
$32.00 |
$0 | to be determined | 4 |
Non-Preferred Brand |
$100.00 | $300.00 | None | $1,382.55 |
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 Access (HMO SNP)
|
$34.30 |
$360 | to be determined | 4 |
Non-Preferred Brand |
50% | 50% | Q:30 /30Days | $1,402.50 |
Browse Plan Formulary |
Healthfirst Increased Benefits Plan (HMO)
|
$35.00 |
$360 | to be determined | 3 |
Tier 3 |
25% | 25% | Q:30 /30Days | $1,358.95 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$35.90 |
$360 | to be determined | 5 |
Tier 5 |
$0.00 | $0.00 | Q:30 /30Days | $1,388.47 |
Browse Plan Formulary |
Humana Gold Plus H3533-010 (HMO)
|
$37.00 |
$360 | to be determined | 5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,377.36 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO SNP)
|
$39.00 |
$360 | to be determined | 3 |
Tier 3 |
$0.00 | $0.00 | Q:30 /30Days | $1,358.39 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO SNP)
|
$39.00 |
$360 | to be determined | 3 |
Tier 3 |
15% | 15% | Q:30 /30Days | $1,358.39 |
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% | Q:30 /30Days | $1,386.10 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$39.30 |
$360 | to be determined | 5 |
Tier 5 |
25% | 25% | Q:30 /30Days | $1,386.55 |
Browse Plan Formulary |
Advantage Value One NY - Dual (HMO SNP)
|
$39.70 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | Q:30 /30Days | $1,434.66 |
Browse Plan Formulary |
Affinity Medicare Solutions (HMO SNP)
|
$39.70 |
$360 | to be determined | 4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:30 /30Days | $1,395.83 |
Browse Plan Formulary |
Affinity Medicare Ultimate (HMO SNP)
|
$39.70 |
$360 | to be determined | 4 |
Non-Preferred Brand |
$90.00 | $225.00 | Q:30 /30Days | $1,395.83 |
Browse Plan Formulary |
AgeWell New York BeWell (HMO SNP)
|
$39.70 |
$360 | to be determined | 1 |
Tier 1 |
15% | 15% | None | $1,389.34 |
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 | $1,389.34 |
Browse Plan Formulary |
AgeWell New York FeelWell (HMO SNP)
|
$39.70 |
$360 | to be determined | 1 |
Tier 1 |
$0.00 | $0.00 | None | $1,389.34 |
Browse Plan Formulary |
CenterLight Healthcare Direct Complete Plan (HMO SNP)
|
$39.70 |
$360 | to be determined | 2 |
Brand |
25% | 25% | P Q:30 /30Days | $1,381.79 |
Browse Plan Formulary |
Elderplan Advantage For Nursing Home Residents (HMO SNP)
|
$39.70 |
$360 | to be determined | 1 |
Tier 1 |
25% | 25% | Q:90 /90Days | $1,391.07 |
Browse Plan Formulary |
Elderplan Extra Help (HMO)
|
$39.70 |
$360 | to be determined | 1 |
Tier 1 |
25% | 25% | Q:90 /90Days | $1,391.07 |
Browse Plan Formulary |
Elderplan For Medicaid Beneficiaries (HMO SNP)
|
$39.70 |
$360 | to be determined | 1 |
Tier 1 |
15% | 15% | Q:90 /90Days | $1,391.07 |
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 |
Elderplan Plus Long Term Care (HMO SNP)
|
$39.70 |
$360 | to be determined | 1 |
Tier 1 |
15% | 15% | Q:90 /90Days | $1,391.06 |
Browse Plan Formulary |
EmblemHealth Dual Eligible (HMO SNP)
|
$39.70 |
$360 | to be determined | 4 |
Non-Preferred Brand |
30% | 30% | None | $1,378.38 |
Browse Plan Formulary |
EmblemHealth Dual Eligible (PPO SNP)
|
$39.70 |
$360 | to be determined | 4 |
Non-Preferred Brand |
30% | 30% | None | $1,378.38 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage (HMO SNP)
|
$39.70 |
$360 | to be determined | 5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,378.79 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO SNP)
|
$39.70 |
$360 | to be determined | 4 |
Non-Preferred Brand |
$100.00 | $200.00 | Q:30 /30Days | $1,396.06 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
|
$39.70 |
$250 | to be determined | 4 |
Non-Preferred Brand |
$100.00 | $200.00 | Q:30 /30Days | $1,396.06 |
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 (HMO SNP)
|
$39.70 |
$360 | to be determined | 4 |
Non-Preferred Brand |
25% | 25% | None | $1,377.45 |
Browse Plan Formulary |
Liberty Health Advantage Dual Power (HMO SNP)
|
$39.70 |
$360 | to be determined | 5 |
Tier 5 |
15% | 15% | Q:30 /30Days | $1,421.63 |
Browse Plan Formulary |
RiverSpring Star (HMO SNP)
|
$39.70 |
$360 | to be determined | 1 |
Tier 1 |
25% | 25% | None | $1,417.83 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Classic (HMO)
|
$39.70 |
$360 | to be determined | 4 |
Tier 4 |
25% | 25% | None | $1,375.03 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Preferred (HMO SNP)
|
$39.70 |
$360 | to be determined | 4 |
Tier 4 |
15% | 15% | None | $1,375.03 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO SNP)
|
$39.70 |
$360 | to be determined | 4 |
Tier 4 |
$0.00 | $0.00 | None | $1,374.68 |
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 |
Affinity Medicare Passport Select (HMO)
|
$41.00 |
$0 | to be determined | 4 |
Non-Preferred Brand |
$95.00 | $237.50 | Q:30 /30Days | $1,395.83 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$49.00 |
$290 | to be determined | 5 |
Specialty Tier |
26% | n/a | P Q:30 /30Days | $1,392.80 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 4 (Regional PPO)
|
$69.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | 33% | Q:30 /30Days | $1,386.10 |
Browse Plan Formulary |
Advantage Platinum Plus NY (HMO)
|
$85.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | Q:30 /30Days | $1,434.66 |
Browse Plan Formulary |
Elderplan Healthy Balance (HMO-POS)
|
$85.00 |
$0 | to be determined | 3 |
Preferred Brand |
$47.00 | $117.50 | Q:90 /90Days | $1,391.12 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Ultra (HMO-POS)
|
$96.40 |
$0 | to be determined | 4 |
Non-Preferred Brand |
$95.00 | $285.00 | None | $1,375.03 |
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 | None | $1,374.27 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
|
$103.00 |
$0 | to be determined | 4 |
Non-Preferred Brand |
$100.00 | $300.00 | None | $1,379.69 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
|
$103.00 |
$0 | to be determined | 4 |
Non-Preferred Brand |
$100.00 | $300.00 | None | $1,376.82 |
Browse Plan Formulary |
EmblemHealth VIP (HMO)
|
$103.00 |
$0 | to be determined | 4 |
Non-Preferred Brand |
$100.00 | $300.00 | None | $1,382.55 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Maximum (HMO SNP)
|
$115.80 |
$360 | to be determined | 4 |
Tier 4 |
$0.00 | $0.00 | None | $1,374.68 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$137.00 |
$225 | to be determined | 4 |
Non-Preferred Brand |
50% | 50% | Q:30 /30Days | $1,401.73 |
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 Connect Plus (PPO)
|
$188.00 |
$0 | to be determined | 4 |
Non-Preferred Brand |
50% | 50% | Q:30 /30Days | $1,399.25 |
Browse Plan Formulary |
EmblemHealth Advantage (PPO)
|
$223.00 |
$0 | to be determined | 4 |
Non-Preferred Brand |
$100.00 | $300.00 | None | $1,380.93 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$306.00 |
$0 | to be determined | 4 |
Non-Preferred Brand |
$100.00 | $300.00 | None | $1,382.55 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$306.00 |
$0 | to be determined | 4 |
Non-Preferred Brand |
$100.00 | $300.00 | None | $1,374.27 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$306.00 |
$0 | to be determined | 4 |
Non-Preferred Brand |
$100.00 | $300.00 | None | $1,379.69 |
Browse Plan Formulary |
EmblemHealth VIP High Option (HMO)
|
$306.00 |
$0 | to be determined | 4 |
Non-Preferred Brand |
$100.00 | $300.00 | None | $1,376.82 |
Browse Plan Formulary |