BCG VACCINE 50mg/1 1 VIAL per CARTON / 1 INJECTION, POWDER, LYOPHILIZED, FOR SOLUTION in 1 VIAL (1 VIAL in 1 CARTON / 1 IN ) (NDC: 00052060302)
2017 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 LI - SNP (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
25% | n/a | None | $153.45 |
Browse Plan Formulary |
Advantage Silver - NY (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
25% | n/a | None | $153.45 |
Browse Plan Formulary |
Aetna Better Health FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | n/a | None | $151.50 |
Browse Plan Formulary |
Aetna Medicare Elite Plan (PPO)
|
$0.00 |
$250* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$5.00 | $15.00 | None | $143.13 |
Browse Plan Formulary |
Affinity Medicare Passport Essentials (HMO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | n/a | None | $159.70 |
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 FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | None | $149.89 |
Browse Plan Formulary |
AgeWell New York LiveWell (HMO)
|
$0.00 |
$370 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
50% | n/a | None | $149.89 |
Browse Plan Formulary |
AgeWell New York LiveWell (HMO)
|
$0.00 |
$370 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
50% | n/a | None | $153.45 |
Browse Plan Formulary |
Elderplan FIDA Total Care (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | None | $150.39 |
Browse Plan Formulary |
EmblemHealth VIP Value (HMO)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
23% | n/a | P | $145.42 |
Browse Plan Formulary |
Fidelis Fully Integrated Dual Advantage Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Tier 2 |
0% | n/a | None | $151.15 |
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 Medicare $0 Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | n/a | None | $151.15 |
Browse Plan Formulary |
Fidelis Medicare $0 Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | n/a | None | $164.08 |
Browse Plan Formulary |
GuildNet Gold Plus FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | P | $145.37 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | n/a | None | $146.22 |
Browse Plan Formulary |
Healthfirst AbsoluteCare FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | None | $146.21 |
Browse Plan Formulary |
Liberty Health Advantage Preferred Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
30% | n/a | None | $154.29 |
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 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | None | $151.14 |
Browse Plan Formulary |
PHP Care Complete FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | None | $146.86 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 1 (Regional PPO)
|
$0.00 |
$290 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $147.54 |
Browse Plan Formulary |
VNSNY CHOICE FIDA Complete (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | P | $148.08 |
Browse Plan Formulary |
WellCare Choice (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $117.50 | None | $162.31 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 3 (Regional PPO)
|
$23.10 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $147.54 |
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)
|
$23.70 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $147.54 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$26.10 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $117.50 | None | $151.36 |
Browse Plan Formulary |
Advantage Value One NY - Dual (HMO SNP)
|
$33.30 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
25% | n/a | None | $153.45 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$34.80 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | n/a | None | $147.54 |
Browse Plan Formulary |
Healthfirst Increased Benefits Plan (HMO)
|
$37.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | None | $146.22 |
Browse Plan Formulary |
Affinity Medicare Solutions (HMO SNP)
|
$38.10 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | n/a | None | $151.14 |
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 |
CenterLight Healthcare Direct Complete Plan (HMO SNP)
|
$38.10 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | P | $148.37 |
Browse Plan Formulary |
Humana Gold Plus H3533-010 (HMO)
|
$39.00 |
$400 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $150.81 |
Browse Plan Formulary |
Affinity Medicare Ultimate (HMO SNP)
|
$40.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | n/a | None | $151.14 |
Browse Plan Formulary |
Elderplan Advantage For Nursing Home Residents (HMO SNP)
|
$40.90 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $150.40 |
Browse Plan Formulary |
Elderplan For Medicaid Beneficiaries (HMO SNP)
|
$40.90 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | None | $150.40 |
Browse Plan Formulary |
Elderplan Plus Long Term Care (HMO SNP)
|
$40.90 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | None | $150.40 |
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 |
AgeWell New York BeWell (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | None | $149.89 |
Browse Plan Formulary |
AgeWell New York CareWell (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $149.89 |
Browse Plan Formulary |
AgeWell New York FeelWell (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | n/a | None | $149.89 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | n/a | P | $145.37 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
23% | n/a | P | $152.26 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
23% | n/a | P | $152.26 |
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 Essential (HMO)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
23% | n/a | P | $145.42 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
23% | n/a | P | $145.42 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | n/a | None | $151.15 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
|
$41.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35.00 | n/a | None | $151.15 |
Browse Plan Formulary |
GuildNet Gold (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | n/a | P | $145.37 |
Browse Plan Formulary |
Healthfirst AssuredCare (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | None | $146.22 |
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 |
Healthfirst CompleteCare (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | n/a | None | $146.22 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | n/a | None | $146.22 |
Browse Plan Formulary |
Liberty Health Advantage Dual Power (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | n/a | None | $154.29 |
Browse Plan Formulary |
Senior Whole Health of New York NHC (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | None | $145.37 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | n/a | None | $147.54 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Classic (HMO)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | P | $148.08 |
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)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | P | $148.08 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | n/a | P | $148.13 |
Browse Plan Formulary |
Affinity Medicare Passport Select (HMO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | n/a | None | $151.14 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$49.00 |
$270 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | None | $152.09 |
Browse Plan Formulary |
Elderplan Healthy Balance (HMO-POS)
|
$93.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | n/a | None | $157.60 |
Browse Plan Formulary |
Advantage Premium - LI (HMO)
|
$95.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
25% | n/a | None | $153.45 |
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 |
EmblemHealth VIP Gold (HMO)
|
$98.00 |
$330 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
23% | n/a | P | $152.26 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$98.00 |
$330 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
23% | n/a | P | $152.26 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$98.00 |
$330 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
23% | n/a | P | $145.42 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$98.00 |
$330 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
23% | n/a | P | $145.42 |
Browse Plan Formulary |
Empire MediBlue Choice (HMO-POS)
|
$99.00 |
$275 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | None | $152.09 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$105.00 |
$200* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$5.00 | $15.00 | None | $146.12 |
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 Maximum (HMO SNP)
|
$109.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | n/a | P | $148.13 |
Browse Plan Formulary |
EmblemHealth VIP Gold Plus (HMO)
|
$295.00 |
$330 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
23% | n/a | P | $152.26 |
Browse Plan Formulary |
EmblemHealth VIP Gold Plus (HMO)
|
$295.00 |
$330 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
23% | n/a | P | $152.26 |
Browse Plan Formulary |
EmblemHealth VIP Gold Plus (HMO)
|
$295.00 |
$330 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
23% | n/a | P | $145.42 |
Browse Plan Formulary |
EmblemHealth VIP Gold Plus (HMO)
|
$295.00 |
$330 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
23% | n/a | P | $145.42 |
Browse Plan Formulary |