NOXAFIL DR 100 MG TABLET (60 EA ) (NDC: 00085432402)
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 Mosaic (HMO)
|
$0.00 |
$245 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | 28% | P Q:240 /30Days | $6,027.46 |
Browse Plan Formulary |
Aetna Medicare Elite Plan (PPO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | P | $5,720.00 |
Browse Plan Formulary |
Affinity Medicare Passport Essentials NYC (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
27% | n/a | None | $5,727.24 |
Browse Plan Formulary |
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 | $5,588.77 |
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 | $5,586.48 |
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 |
4 |
Non-Preferred Brand |
50% | n/a | None | $5,696.32 |
Browse Plan Formulary |
Centers Plan for FIDA Care Complete (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | None | $5,663.13 |
Browse Plan Formulary |
Centers Plan for Medicare Advantage Care (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | n/a | None | $5,636.69 |
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 | $5,706.98 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | P Q:240 /30Days | $5,534.42 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | P Q:240 /30Days | $5,545.31 |
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 |
$250 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | P Q:240 /30Days | $5,546.24 |
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 | $5,727.25 |
Browse Plan Formulary |
Fidelis Medicare $0 Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $5,727.59 |
Browse Plan Formulary |
Fidelis Medicare $0 Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $5,726.45 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $5,557.67 |
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 | $5,557.67 |
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 |
ICS Community Care Plus FIDA MMP (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | None | $5,663.22 |
Browse Plan Formulary |
Liberty Health Advantage Preferred Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $5,829.72 |
Browse Plan Formulary |
MetroPlus FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | None | $5,727.22 |
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 | $5,576.93 |
Browse Plan Formulary |
SWH Whole Health FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | None | $5,543.40 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 1 (Regional PPO)
|
$0.00 |
$290 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | 27% | P Q:240 /30Days | $5,864.15 |
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 |
VillageCareMAX Full Advantage FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | None | $5,663.22 |
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 | None | $5,617.45 |
Browse Plan Formulary |
WellCare Choice (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $5,754.20 |
Browse Plan Formulary |
WellCare Rx (HMO)
|
$7.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $5,754.20 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$19.00 |
$330 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
26% | 26% | P Q:240 /30Days | $6,027.46 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 3 (Regional PPO)
|
$23.10 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | 30% | P Q:240 /30Days | $5,864.15 |
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 |
UnitedHealthcare MedicareComplete Choice Plan 4 (Regional PPO)
|
$23.70 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P Q:240 /30Days | $5,864.15 |
Browse Plan Formulary |
Humana Gold Plus H3533-021 (HMO)
|
$24.10 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:93 /30Days | $5,631.66 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$26.10 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $5,754.20 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$29.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
27% | n/a | P | $5,709.21 |
Browse Plan Formulary |
Fidelis Medicaid Advantage Plus (HMO SNP)
|
$33.70 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $5,727.25 |
Browse Plan Formulary |
Fidelis Dual Advantage (HMO SNP)
|
$34.60 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $5,726.51 |
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)
|
$34.60 |
$260 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | n/a | P Q:93 /30Days | $5,631.66 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$34.80 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | n/a | P Q:240 /30Days | $6,031.02 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
|
$35.00 |
$230 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | 28% | P Q:240 /30Days | $6,027.46 |
Browse Plan Formulary |
Healthfirst Increased Benefits Plan (HMO)
|
$37.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | None | $5,557.67 |
Browse Plan Formulary |
Affinity Medicare Solutions (HMO SNP)
|
$38.10 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $5,727.12 |
Browse Plan Formulary |
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 | $5,616.85 |
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 |
Affinity Medicare Ultimate (HMO SNP)
|
$40.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $5,727.12 |
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 | $5,706.97 |
Browse Plan Formulary |
Elderplan Extra Help (HMO)
|
$40.90 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $5,706.99 |
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 | $5,706.99 |
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 | $5,706.99 |
Browse Plan Formulary |
Fresenius Total Health (HMO SNP)
|
$40.90 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $5,573.53 |
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 |
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 | $5,588.77 |
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 | $5,588.77 |
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 | $5,588.77 |
Browse Plan Formulary |
ArchCare Advantage (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $5,727.25 |
Browse Plan Formulary |
Centers Plan for Dual Coverage Care (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | n/a | None | $5,663.12 |
Browse Plan Formulary |
Centers Plan for Nursing Home Care (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | None | $5,636.69 |
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)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $5,726.47 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
|
$41.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | None | $5,726.47 |
Browse Plan Formulary |
Healthfirst AssuredCare (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | None | $5,557.67 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | n/a | None | $5,557.67 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | n/a | None | $5,557.67 |
Browse Plan Formulary |
Liberty Health Advantage Dual Power (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | n/a | None | $5,829.72 |
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 |
MetroPlus Advantage Plan (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | None | $5,557.67 |
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 | $5,545.88 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | n/a | P Q:240 /30Days | $5,861.59 |
Browse Plan Formulary |
VillageCareMAX Medicare Health Advantage (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | None | $5,663.22 |
Browse Plan Formulary |
VillageCareMAX Medicare Total Advantage (HMO SNP)
|
$41.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | n/a | None | $5,663.22 |
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 | None | $5,617.69 |
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 | None | $5,617.69 |
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 | None | $5,618.77 |
Browse Plan Formulary |
Affinity Medicare Passport Select (HMO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $5,727.12 |
Browse Plan Formulary |
WellCare Preferred (HMO-POS)
|
$45.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | None | $5,754.20 |
Browse Plan Formulary |
AARP MedicareComplete Plan 3 (HMO)
|
$66.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P Q:240 /30Days | $6,027.46 |
Browse Plan Formulary |
Empire MediBlue Access (PPO)
|
$70.00 |
$260 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
27% | n/a | P Q:240 /30Days | $5,551.64 |
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 |
Aetna Medicare Premier Plan (PPO)
|
$99.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
29% | n/a | P | $5,710.54 |
Browse Plan Formulary |
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 | None | $5,618.77 |
Browse Plan Formulary |
MetroPlus Platinum (HMO)
|
$226.20 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $5,557.67 |
Browse Plan Formulary |