HYDROMORPHONE 1 MG/ML SOLUTION [Dilaudid] (473 ML ) (NDC: 00054038663)
2018 Medicare Prescription Drug Plan (MAPD) Information
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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 |
$295 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:2700 /30Days | $142.85 |
Browse Plan Formulary |
Advantage Health NYC - SNP (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | n/a | None | $220.02 |
Browse Plan Formulary |
Advantage Silver - NY City (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | n/a | None | $220.02 |
Browse Plan Formulary |
Aetna Medicare Elite Plan (PPO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:2400 /30Days | $121.70 |
Browse Plan Formulary |
Affinity Medicare Passport Essentials NYC (HMO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | n/a | None | $213.29 |
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 |
Centers Plan for FIDA Care Complete (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Generic Drugs |
0% | n/a | Q:1200 /30Days | $165.11 |
Browse Plan Formulary |
Centers Plan for Medicare Advantage Care (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$3.00 | n/a | Q:1200 /30Days | $165.01 |
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 | None | $213.53 |
Browse Plan Formulary |
EmblemHealth VIP Value (HMO)
|
$0.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$16.00 | n/a | Q:1500 /30Days | $144.23 |
Browse Plan Formulary |
Fidelis Medicare $0 Premium (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | n/a | None | $213.53 |
Browse Plan Formulary |
Fidelis Medicare $0 Premium (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | n/a | None | $213.53 |
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 |
GuildNet Gold Plus FIDA Plan POS (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Generic Drugs |
0% | n/a | Q:1500 /30Days | $147.84 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | None | $213.29 |
Browse Plan Formulary |
Healthfirst AbsoluteCare FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Generic Drugs |
0% | n/a | None | $213.29 |
Browse Plan Formulary |
RiverSpring FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Generic Drugs |
0% | n/a | None | $210.84 |
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:1200 /30Days | $161.73 |
Browse Plan Formulary |
WellCare Choice (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
48% | 48% | None | $213.29 |
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 |
WellCare Choice (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
48% | 48% | None | $213.29 |
Browse Plan Formulary |
WellCare Rx (HMO)
|
$14.50 |
$405 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | None | $213.29 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 1 (Regional PPO)
|
$17.00 |
$350 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:2700 /30Days | $141.90 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$25.30 |
$405 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | n/a | Q:2700 /30Days | $145.73 |
Browse Plan Formulary |
Advantage Value One NY - Dual (HMO SNP)
|
$25.80 |
$405 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $211.84 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$27.00 |
$330 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:2700 /30Days | $142.85 |
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 |
Aetna Medicare Select Plan (HMO)
|
$28.00 |
$200 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:2400 /30Days | $128.18 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 3 (Regional PPO)
|
$28.20 |
$225 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:2700 /30Days | $141.90 |
Browse Plan Formulary |
Fidelis Medicaid Advantage Plus (HMO SNP)
|
$28.40 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | n/a | None | $213.53 |
Browse Plan Formulary |
Healthfirst Increased Benefits Plan (HMO)
|
$29.70 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | None | $213.29 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$33.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | n/a | Q:2700 /30Days | $141.61 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 4 (Regional PPO)
|
$35.70 |
$100 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:2700 /30Days | $141.90 |
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)
|
$36.90 |
$405 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | None | $213.29 |
Browse Plan Formulary |
Spartan Plan NY I-SNP (HMO SNP)
|
$37.10 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
25% | n/a | Q:2400 /30Days | $396.41 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
|
$38.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | n/a | None | $213.53 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO SNP)
|
$38.40 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | n/a | None | $213.53 |
Browse Plan Formulary |
Fidelis Dual Advantage (HMO SNP)
|
$38.80 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | n/a | None | $213.53 |
Browse Plan Formulary |
Affinity Medicare Solutions (HMO SNP)
|
$39.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$99.00 | n/a | None | $213.29 |
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 |
Affinity Medicare Ultimate (HMO SNP)
|
$39.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | n/a | None | $213.29 |
Browse Plan Formulary |
ArchCare Advantage (HMO SNP)
|
$39.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $213.53 |
Browse Plan Formulary |
CenterLight Healthcare Direct Complete Plan (HMO SNP)
|
$39.00 |
$405* | No additional gap coverage, only the Donut Hole Discount | 1* |
Generic |
$10.25 | n/a | Q:2400 /30Days | $395.09 |
Browse Plan Formulary |
Centers Plan for Dual Coverage Care (HMO SNP)
|
$39.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | n/a | Q:1200 /30Days | $165.10 |
Browse Plan Formulary |
Centers Plan for Nursing Home Care (HMO SNP)
|
$39.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | Q:1200 /30Days | $165.01 |
Browse Plan Formulary |
Elderplan Advantage For Nursing Home Residents (HMO SNP)
|
$39.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $213.53 |
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 |
Elderplan Plus Long Term Care (HMO SNP)
|
$39.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | n/a | None | $213.53 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO SNP)
|
$39.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | n/a | Q:1500 /30Days | $143.96 |
Browse Plan Formulary |
GuildNet Gold (HMO SNP)
|
$39.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | n/a | Q:1500 /30Days | $144.20 |
Browse Plan Formulary |
Healthfirst AssuredCare (HMO SNP)
|
$39.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | None | $213.29 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO SNP)
|
$39.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | n/a | None | $213.29 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO SNP)
|
$39.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | n/a | None | $213.29 |
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 |
RiverSpring MAP (HMO SNP)
|
$39.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | n/a | None | $210.84 |
Browse Plan Formulary |
RiverSpring Star (HMO SNP)
|
$39.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $210.84 |
Browse Plan Formulary |
Spartan Plan NY (HMO)
|
$39.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
25% | n/a | Q:2400 /30Days | $396.41 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Classic (HMO)
|
$39.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | Q:1200 /30Days | $161.63 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Preferred (HMO SNP)
|
$39.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | Q:1200 /30Days | $161.63 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO SNP)
|
$39.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | n/a | Q:1200 /30Days | $161.76 |
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)
|
$46.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$16.00 | n/a | Q:1500 /30Days | $144.04 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$46.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$16.00 | n/a | Q:1500 /30Days | $144.14 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$46.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$16.00 | n/a | Q:1500 /30Days | $144.71 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$46.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$16.00 | n/a | Q:1500 /30Days | $144.14 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
|
$47.00 |
$295 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:2700 /30Days | $142.85 |
Browse Plan Formulary |
Spartan Plan NY C-SNP (HMO SNP)
|
$49.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
25% | n/a | Q:2400 /30Days | $396.41 |
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 Preferred (HMO-POS)
|
$53.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
48% | 48% | None | $213.29 |
Browse Plan Formulary |
AARP MedicareComplete Plan 3 (HMO)
|
$83.00 |
$100 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:2700 /30Days | $142.85 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$96.00 |
$150 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:2400 /30Days | $119.10 |
Browse Plan Formulary |
Centers Plan for Medicaid Advantage Plus (HMO SNP)
|
$99.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | n/a | Q:1200 /30Days | $164.96 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$109.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | n/a | Q:1500 /30Days | $144.14 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$109.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | n/a | Q:1500 /30Days | $144.04 |
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)
|
$109.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | n/a | Q:1500 /30Days | $144.71 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$109.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | n/a | Q:1500 /30Days | $144.14 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Maximum (HMO SNP)
|
$119.60 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | Q:1200 /30Days | $161.76 |
Browse Plan Formulary |
EmblemHealth VIP Gold Plus (HMO)
|
$297.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | n/a | Q:1500 /30Days | $144.19 |
Browse Plan Formulary |