LEVOTHYROXINE 200 MCG TABLET (NDC: 00378181977)
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 |
Advantage Health LI - SNP (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | n/a | None | $18.75 |
Browse Plan Formulary |
Advantage Silver - NY (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$15.00 | n/a | None | $18.75 |
Browse Plan Formulary |
Aetna Medicare Elite Plan (PPO)
|
$0.00 |
$250* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $10.12 |
Browse Plan Formulary |
Affinity Medicare Passport Essentials (HMO)
|
$0.00 |
$250* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$10.00 | n/a | None | $18.70 |
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 | $19.66 |
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 |
$225* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$5.00 | n/a | None | $19.62 |
Browse Plan Formulary |
AgeWell New York LiveWell (HMO)
|
$0.00 |
$225* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$5.00 | n/a | None | $19.67 |
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 | $18.75 |
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 | $16.43 |
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 | $18.59 |
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 | $13.15 |
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 |
2 |
Generic |
$20.00 | n/a | None | $13.55 |
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 | $13.05 |
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 | $12.91 |
Browse Plan Formulary |
Humana Gold Plus H3533-027 (HMO)
|
$0.00 |
$400* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$6.00 | $0.00 | None | $17.33 |
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 | $15.97 |
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 | $13.55 |
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 | $15.64 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 1 (Regional PPO)
|
$17.00 |
$350* |
to be determined |
1* |
Preferred Generic |
$3.00 | $0.00 | None | $16.00 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$25.30 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | n/a | None | $16.13 |
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 | $18.84 |
Browse Plan Formulary |
Humana Gold Plus H3533-010 (HMO)
|
$27.20 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$2.00 | $0.00 | None | $17.33 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 3 (Regional PPO)
|
$28.20 |
$225* |
to be determined |
1* |
Preferred Generic |
$3.00 | $0.00 | None | $16.00 |
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 | $13.05 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$33.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $16.48 |
Browse Plan Formulary |
WellCare Choice (HMO)
|
$35.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $18.70 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 4 (Regional PPO)
|
$35.70 |
$100* |
to be determined |
1* |
Preferred Generic |
$3.00 | $0.00 | None | $16.00 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$36.90 |
$405* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $18.70 |
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 | $35.38 |
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 |
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 | $13.12 |
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 | $13.15 |
Browse Plan Formulary |
Affinity Medicare Solutions (HMO SNP)
|
$39.00 |
$405* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$2.00 | n/a | None | $18.70 |
Browse Plan Formulary |
Affinity Medicare Ultimate (HMO SNP)
|
$39.00 |
$405* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$3.00 | n/a | None | $18.70 |
Browse Plan Formulary |
AgeWell New York BeWell (HMO SNP)
|
$39.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | None | $19.66 |
Browse Plan Formulary |
AgeWell New York CareWell (HMO SNP)
|
$39.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $19.66 |
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 FeelWell (HMO SNP)
|
$39.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | n/a | None | $19.66 |
Browse Plan Formulary |
AgeWell New York StayWell (HMO)
|
$39.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $19.66 |
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 | None | $35.09 |
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 | $16.14 |
Browse Plan Formulary |
Elderplan For Medicaid Beneficiaries (HMO SNP)
|
$39.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | None | $16.48 |
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 | $16.37 |
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 Dual (HMO SNP)
|
$39.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | n/a | None | $17.58 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage (HMO SNP)
|
$39.00 |
$405* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$0.00 | n/a | None | $17.61 |
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 | $13.05 |
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 | $12.92 |
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 | $12.92 |
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 | $13.55 |
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 | $13.55 |
Browse Plan Formulary |
Senior Whole Health of New York NHC (HMO SNP)
|
$39.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | None | $17.67 |
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 | $35.38 |
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 | $15.63 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Preferred (HMO SNP)
|
$39.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$4.00 | n/a | None | $15.63 |
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 | None | $15.67 |
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 |
EmblemHealth VIP Essential (HMO)
|
$46.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | n/a | None | $18.03 |
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 | $19.01 |
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 | $19.25 |
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 | $17.44 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$46.00 |
$350* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$4.00 | n/a | None | $19.42 |
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 | $35.38 |
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 |
Empire MediBlue Choice (HMO-POS)
|
$66.00 |
$350* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$4.00 | n/a | None | $19.42 |
Browse Plan Formulary |
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 | $17.33 |
Browse Plan Formulary |
Advantage Premium - LI (HMO)
|
$78.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | n/a | None | $18.75 |
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 | $18.77 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$105.00 |
$200* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $10.50 |
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 | $18.03 |
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 | $19.01 |
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 | $19.25 |
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 | $17.44 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Maximum (HMO SNP)
|
$119.60 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$5.00 | n/a | None | $15.67 |
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 | $18.28 |
Browse Plan Formulary |