HYDROCODONE BITARTRATE AND IBUPROFEN TABLET 7.5-200MG (100 CT) (100 BOT) (NDC: 53746014501)
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 |
AARP MedicareComplete Plan 1 (HMO)
|
$0.00 |
$245 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:150 /30Days | $128.91 |
Browse Plan Formulary |
Aetna Medicare Elite Plan (PPO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:150 /30Days | $92.34 |
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 | Q:150 /30Days | $90.20 |
Browse Plan Formulary |
AgeWell New York FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | n/a | None | $87.98 |
Browse Plan Formulary |
AgeWell New York LiveWell (HMO)
|
$0.00 |
$370* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$20.00 | n/a | None | $95.38 |
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 |
AgeWell New York LiveWell (HMO)
|
$0.00 |
$370* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$20.00 | n/a | None | $86.58 |
Browse Plan Formulary |
BasiCare with Part D (PPO)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $20.00 | Q:150 /30Days | $89.98 |
Browse Plan Formulary |
Elderplan FIDA Total Care (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | n/a | Q:150 /30Days | $64.27 |
Browse Plan Formulary |
EmblemHealth VIP Value (HMO)
|
$0.00 |
$400* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$16.00 | n/a | Q:50 /30Days | $66.12 |
Browse Plan Formulary |
Fidelis Fully Integrated Dual Advantage Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | n/a | Q:150 /30Days | $117.59 |
Browse Plan Formulary |
GuildNet Gold Plus FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | n/a | Q:50 /30Days | $61.98 |
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 |
Healthfirst AbsoluteCare FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | n/a | Q:150 /30Days | $47.04 |
Browse Plan Formulary |
PHP Care Complete FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | n/a | None | $51.36 |
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 | Q:150 /30Days | $124.71 |
Browse Plan Formulary |
VNSNY CHOICE FIDA Complete (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | n/a | Q:150 /30Days | $77.51 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$15.30 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$44.00 | $110.00 | Q:150 /30Days | $103.81 |
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 | Q:150 /30Days | $124.71 |
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 | Q:150 /30Days | $124.71 |
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 | Q:150 /30Days | $125.79 |
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 | Q:150 /30Days | $90.20 |
Browse Plan Formulary |
CenterLight Healthcare Direct Complete Plan (HMO SNP)
|
$38.10 |
$400* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Generic |
$9.00 | n/a | Q:480 /30Days | $79.50 |
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 | Q:150 /30Days | $90.20 |
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 | Q:150 /30Days | $60.93 |
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)
|
$40.90 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | Q:150 /30Days | $65.27 |
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 | Q:150 /30Days | $63.03 |
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 | Q:150 /30Days | $62.78 |
Browse Plan Formulary |
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 | $87.98 |
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 | $87.98 |
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 | $87.98 |
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 |
ArchCare Advantage (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | Q:150 /30Days | $127.20 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | n/a | Q:50 /30Days | $63.01 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | n/a | Q:150 /30Days | $135.54 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
|
$41.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | n/a | Q:150 /30Days | $135.54 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | n/a | Q:150 /30Days | $47.05 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | Q:150 /30Days | $47.05 |
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 |
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 | Q:50 /30Days | $61.06 |
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 | Q:150 /30Days | $77.53 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Preferred (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | Q:150 /30Days | $77.53 |
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 | Q:150 /30Days | $77.57 |
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 | Q:150 /30Days | $90.20 |
Browse Plan Formulary |
WellCare Preferred (HMO-POS)
|
$45.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $117.50 | Q:150 /30Days | $103.85 |
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 |
Today's Options Advantage Plus 750B (PPO)
|
$56.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$37.00 | $74.00 | Q:150 /30Days | $104.30 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$57.00 |
$400* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$16.00 | n/a | Q:50 /30Days | $66.91 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$57.00 |
$400* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$16.00 | n/a | Q:50 /30Days | $65.02 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$57.00 |
$400* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$16.00 | n/a | Q:50 /30Days | $62.57 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$57.00 |
$400* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$16.00 | n/a | Q:50 /30Days | $70.42 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$66.00 |
$240 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:150 /30Days | $128.91 |
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 |
Empire MediBlue Plus (HMO)
|
$86.00 |
$275 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | n/a | Q:50 /30Days | $115.49 |
Browse Plan Formulary |
Elderplan Healthy Balance (HMO-POS)
|
$93.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$12.00 | n/a | Q:150 /30Days | $47.97 |
Browse Plan Formulary |
GoldValue with Part D (HMO-POS)
|
$98.80 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$15.00 | $30.00 | Q:150 /30Days | $89.98 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$99.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:150 /30Days | $92.70 |
Browse Plan Formulary |
Today's Options Advantage Plus 450A (PPO)
|
$103.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:150 /30Days | $104.30 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$107.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:150 /30Days | $92.63 |
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 |
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 | Q:150 /30Days | $77.57 |
Browse Plan Formulary |
Gold PPO with Part D (PPO)
|
$117.40 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $20.00 | Q:150 /30Days | $89.98 |
Browse Plan Formulary |
Preferred Gold with Part D (HMO-POS)
|
$166.80 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $20.00 | Q:150 /30Days | $89.98 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$229.00 |
$330* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | Q:50 /30Days | $66.91 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$229.00 |
$330* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | Q:50 /30Days | $65.02 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$229.00 |
$330* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | Q:50 /30Days | $62.57 |
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)
|
$229.00 |
$330* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | Q:50 /30Days | $70.42 |
Browse Plan Formulary |
EmblemHealth VIP Gold Plus (HMO)
|
$320.00 |
$330* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | Q:50 /30Days | $66.91 |
Browse Plan Formulary |
EmblemHealth VIP Gold Plus (HMO)
|
$320.00 |
$330* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | Q:50 /30Days | $65.02 |
Browse Plan Formulary |
EmblemHealth VIP Gold Plus (HMO)
|
$320.00 |
$330* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | Q:50 /30Days | $62.57 |
Browse Plan Formulary |
EmblemHealth VIP Gold Plus (HMO)
|
$320.00 |
$330* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | Q:50 /30Days | $70.42 |
Browse Plan Formulary |