Leucovorin Calcium 15mg/1 24 TABLET BOTTLE (24 TABLET in 1 BOTTLE ) (NDC: 00054449810)
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 | $1,176.66 |
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 | $1,176.66 |
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 | $1,131.37 |
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 | None | $1,060.39 |
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 | $1,180.06 |
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. | 2* |
Generic |
$15.00 | n/a | None | $1,174.49 |
Browse Plan Formulary |
AgeWell New York LiveWell (HMO)
|
$0.00 |
$225* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$15.00 | n/a | None | $1,181.88 |
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 | $921.73 |
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 | $1,060.63 |
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 | None | $1,140.16 |
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 | $1,060.63 |
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 |
Fidelis Medicare $0 Premium (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | n/a | None | $1,060.63 |
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 | $1,060.39 |
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 | $1,060.38 |
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 | $663.86 |
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 | $1,103.91 |
Browse Plan Formulary |
RiverSpring FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Brand Drugs |
0% | n/a | None | $648.59 |
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 |
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 | $689.84 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 1 (Regional PPO)
|
$17.00 |
$350 | to be determined | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $992.46 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$25.30 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
$0.00 | n/a | None | $992.08 |
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 | $1,175.74 |
Browse Plan Formulary |
Humana Gold Plus H3533-010 (HMO)
|
$27.20 |
$250* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$9.00 | $0.00 | None | $665.98 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 3 (Regional PPO)
|
$28.20 |
$225 | to be determined | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $992.46 |
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 | $1,060.39 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$33.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | n/a | None | $992.75 |
Browse Plan Formulary |
WellCare Choice (HMO)
|
$35.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $117.50 | None | $1,060.38 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 4 (Regional PPO)
|
$35.70 |
$100 | to be determined | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $992.46 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$36.90 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $117.50 | None | $1,060.38 |
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 | $1,304.50 |
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 | $1,060.63 |
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 | $1,060.63 |
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 | $1,060.39 |
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 | $1,060.39 |
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 | $1,180.06 |
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 | $1,180.06 |
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 | $1,180.06 |
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 | $1,180.06 |
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 | $1,294.26 |
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 | $1,060.63 |
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 | $1,060.63 |
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 | $1,060.63 |
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 |
EmblemHealth VIP Dual (HMO SNP)
|
$39.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | n/a | None | $1,027.58 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage (HMO SNP)
|
$39.00 |
$405 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $1,026.16 |
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 | $1,060.39 |
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 | $1,060.39 |
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 | $1,060.39 |
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 | $648.59 |
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 |
RiverSpring Star (HMO SNP)
|
$39.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $648.59 |
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 | $1,026.16 |
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 | $1,304.50 |
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 | $692.73 |
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 | $692.73 |
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 | $689.87 |
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 |
EmblemHealth VIP Essential (HMO)
|
$46.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$16.00 | n/a | None | $1,116.04 |
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 | None | $1,162.33 |
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 | None | $1,171.11 |
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 | None | $1,119.46 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$46.00 |
$350 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$15.00 | n/a | None | $1,169.94 |
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 | $1,304.50 |
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. | 2 |
Generic |
$15.00 | n/a | None | $1,169.94 |
Browse Plan Formulary |
Humana Gold Plus H3533-023 (HMO)
|
$67.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$9.00 | $0.00 | None | $663.86 |
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 | $1,176.66 |
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 | $921.86 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$105.00 |
$200 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $121.00 | None | $1,131.37 |
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 | None | $1,162.33 |
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 | None | $1,116.04 |
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 | None | $1,171.11 |
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 | None | $1,119.46 |
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 | $689.87 |
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 | None | $1,124.56 |
Browse Plan Formulary |