HYDROXYCHLOROQUINE 200 MG TAB (100 EA ) (NDC: 68382009601)
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 | 2* |
Generic |
$12.00 | $0.00 | None | $44.92 |
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 | $56.93 |
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 | $56.93 |
Browse Plan Formulary |
Aetna Medicare Elite Plan (PPO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $121.00 | None | $51.77 |
Browse Plan Formulary |
Affinity Medicare Passport Essentials NYC (HMO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | n/a | None | $89.01 |
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 | None | $16.80 |
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 | None | $16.90 |
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 | $78.55 |
Browse Plan Formulary |
EmblemHealth VIP Value (HMO)
|
$0.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | n/a | None | $24.19 |
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 | $65.79 |
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 | $64.59 |
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 | None | $24.81 |
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 | $17.69 |
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 | $17.98 |
Browse Plan Formulary |
Humana Gold Plus H3533-027 (HMO)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $43.07 |
Browse Plan Formulary |
PHP Care Complete FIDA-IDD Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Generic Drugs |
0% | n/a | None | $13.42 |
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 | $71.04 |
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 |
VNSNY CHOICE FIDA Complete (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Generic Drugs |
0% | n/a | None | $17.98 |
Browse Plan Formulary |
WellCare Choice (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $37.50 | None | $85.01 |
Browse Plan Formulary |
WellCare Choice (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $37.50 | None | $85.01 |
Browse Plan Formulary |
WellCare Rx (HMO)
|
$14.50 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$17.00 | $42.50 | None | $85.01 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 1 (Regional PPO)
|
$17.00 |
$350* | to be determined | 2* |
Generic |
$12.00 | $0.00 | None | $41.99 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$25.30 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | n/a | None | $42.85 |
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 |
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 | $54.27 |
Browse Plan Formulary |
Humana Gold Plus H3533-021 (HMO)
|
$26.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$2.00 | $0.00 | None | $43.07 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$27.00 |
$330* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$12.00 | $0.00 | None | $44.92 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$28.00 |
$200 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $121.00 | None | $51.38 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 3 (Regional PPO)
|
$28.20 |
$225* | to be determined | 2* |
Generic |
$12.00 | $0.00 | None | $41.99 |
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 | $62.87 |
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 Increased Benefits Plan (HMO)
|
$29.70 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | None | $17.69 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$33.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | None | $44.06 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H3533-004 (HMO SNP)
|
$34.30 |
$320* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $43.07 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 4 (Regional PPO)
|
$35.70 |
$100* | to be determined | 2* |
Generic |
$12.00 | $0.00 | None | $41.99 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$36.90 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$3.00 | $7.50 | None | $85.01 |
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 | None | $36.41 |
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 |
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 | $64.42 |
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 | $64.49 |
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 | $65.04 |
Browse Plan Formulary |
Affinity Medicare Solutions (HMO SNP)
|
$39.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | n/a | None | $89.01 |
Browse Plan Formulary |
Affinity Medicare Ultimate (HMO SNP)
|
$39.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | n/a | None | $89.01 |
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 | $98.88 |
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)
|
$39.00 |
$405* | No additional gap coverage, only the Donut Hole Discount | 1* |
Generic |
$10.25 | n/a | None | $35.81 |
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 | None | $16.80 |
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 | None | $16.83 |
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 | $78.55 |
Browse Plan Formulary |
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 | $78.55 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO SNP)
|
$39.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | n/a | None | $23.30 |
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 Dual Advantage (HMO SNP)
|
$39.00 |
$405 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $40.62 |
Browse Plan Formulary |
GuildNet Gold (HMO SNP)
|
$39.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$2.00 | n/a | None | $22.51 |
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 | $17.69 |
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 | $17.99 |
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 | $17.99 |
Browse Plan Formulary |
RiverSpring MAP (HMO SNP)
|
$39.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | n/a | None | $71.04 |
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 |
RiverSpring Star (HMO SNP)
|
$39.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $71.04 |
Browse Plan Formulary |
Spartan Plan NY (HMO)
|
$39.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
25% | n/a | None | $36.41 |
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 | None | $18.01 |
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 | None | $18.01 |
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 | None | $18.01 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$46.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | n/a | None | $22.64 |
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 |
EmblemHealth VIP Essential (HMO)
|
$46.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | n/a | None | $23.44 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$46.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | n/a | None | $24.94 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$46.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | n/a | None | $25.54 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
|
$47.00 |
$295* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$12.00 | $0.00 | None | $44.92 |
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 | None | $36.41 |
Browse Plan Formulary |
WellCare Preferred (HMO-POS)
|
$53.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $37.50 | None | $85.01 |
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 H3533-023 (HMO)
|
$67.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $43.07 |
Browse Plan Formulary |
AARP MedicareComplete Plan 3 (HMO)
|
$83.00 |
$100* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$12.00 | $0.00 | None | $44.92 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$96.00 |
$150 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $121.00 | None | $52.20 |
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 | None | $16.91 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$109.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | n/a | None | $24.94 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$109.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | n/a | None | $25.54 |
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 |
EmblemHealth VIP Gold (HMO)
|
$109.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | n/a | None | $22.64 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$109.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | n/a | None | $23.44 |
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 | None | $18.01 |
Browse Plan Formulary |
EmblemHealth VIP Gold Plus (HMO)
|
$297.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | n/a | None | $23.59 |
Browse Plan Formulary |