OXYCODONE HCL 5 MG TABLET [Roxybond] (100 EA ) (NDC: 10702001801)
2019 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 |
Aetna Medicare Elite Plan (PPO)
|
$0.00 |
$245 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $136.00 | Q:180 /30Days | $41.84 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$195 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $136.00 | Q:180 /30Days | $44.76 |
Browse Plan Formulary |
Affinity Medicare Passport Essentials NYC (HMO)
|
$0.00 |
$295 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $117.50 | Q:180 /30Days | $19.80 |
Browse Plan Formulary |
Centers Plan for FIDA Care Complete (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Generic Drugs |
0% | 0% | Q:180 /30Days | $24.39 |
Browse Plan Formulary |
Centers Plan for Medicare Advantage Care (HMO)
|
$0.00 |
$395* | No additional gap coverage, only the Donut Hole Discount | 1* |
Generic |
$5.00 | $8.00 | Q:180 /30Days | $24.45 |
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 FIDA Total Care (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Generic Drugs |
0% | 0% | Q:180 /30Days | $7.39 |
Browse Plan Formulary |
EmblemHealth VIP Part B Saver (HMO)
|
$0.00 |
$415 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$18.00 | $54.00 | Q:360 /30Days | $20.52 |
Browse Plan Formulary |
EmblemHealth VIP Value (HMO)
|
$0.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$18.00 | $54.00 | Q:360 /30Days | $20.58 |
Browse Plan Formulary |
Empire MediBlue Select (HMO)
|
$0.00 |
$350 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:180 /30Days | $29.68 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$350 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $47.00 | Q:180 /30Days | $15.77 |
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% | 0% | Q:180 /30Days | $15.77 |
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 H3533-027 (HMO)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $11.32 |
Browse Plan Formulary |
HumanaChoice H5970-021 (PPO)
|
$0.00 |
$350* | No additional gap coverage, only the Donut Hole Discount | 3* |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $11.32 |
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% | 0% | Q:120 /30Days | $18.95 |
Browse Plan Formulary |
RiverSpring FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Generic Drugs |
0% | 0% | Q:180 /30Days | $33.84 |
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% | 0% | Q:180 /30Days | $22.43 |
Browse Plan Formulary |
WellCare Choice (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:180 /30Days | $12.77 |
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)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:180 /30Days | $15.48 |
Browse Plan Formulary |
WellCare Rx (HMO)
|
$14.70 |
$415 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:180 /30Days | $16.19 |
Browse Plan Formulary |
WellCare Rx (HMO)
|
$14.70 |
$415 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:180 /30Days | $12.71 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 1 (Regional PPO)
|
$16.00 |
$350* | to be determined | 2* |
Generic |
$12.00 | $0.00 | Q:360 /30Days | $22.96 |
Browse Plan Formulary |
Humana Gold Plus H3533-021 (HMO)
|
$21.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $11.33 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 3 (Regional PPO)
|
$21.20 |
$275* | to be determined | 2* |
Generic |
$12.00 | $0.00 | Q:360 /30Days | $22.96 |
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 |
AARP MedicareComplete Plan 2 (HMO)
|
$26.00 |
$415* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$12.00 | $0.00 | Q:360 /30Days | $21.66 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$28.50 |
$415 | No additional gap coverage, only the Donut Hole Discount | 2 |
All Formulary Drugs |
$0.00 | $0.00 | Q:360 /30Days | $23.04 |
Browse Plan Formulary |
Fidelis Medicaid Advantage Plus (HMO SNP)
|
$29.20 |
$415 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$14.50 | $29.00 | Q:180 /30Days | $7.79 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 4 (Regional PPO)
|
$33.60 |
$150* | to be determined | 2* |
Generic |
$12.00 | $0.00 | Q:360 /30Days | $22.96 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$33.60 |
$415 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$44.00 | $88.00 | Q:180 /30Days | $12.77 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$33.60 |
$415 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$44.00 | $88.00 | Q:180 /30Days | $13.90 |
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 |
UnitedHealthcare Nursing Home Plan 2 (HMO SNP)
|
$35.40 |
$415 | No additional gap coverage, only the Donut Hole Discount | 2 |
All Formulary Drugs |
25% | 25% | Q:360 /30Days | $22.06 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H3533-004 (HMO SNP)
|
$35.70 |
$385 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $11.33 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO SNP)
|
$36.10 |
$415 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $40.00 | Q:180 /30Days | $7.79 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 1 (PPO SNP)
|
$36.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 2 |
All Formulary Drugs |
25% | 25% | Q:360 /30Days | $22.10 |
Browse Plan Formulary |
Fidelis Dual Advantage (HMO SNP)
|
$38.90 |
$415 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $40.00 | Q:180 /30Days | $7.80 |
Browse Plan Formulary |
MetroPlus Advantage Plan (HMO SNP)
|
$39.00 |
$415 | No additional gap coverage, only the Donut Hole Discount | 1 |
All Formulary Drugs |
15% | 15% | Q:180 /30Days | $7.76 |
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 |
Sunrise Advantage Plan (HMO)
|
$39.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | n/a | Q:360 /30Days | $16.05 |
Browse Plan Formulary |
Affinity Medicare Solutions (HMO SNP)
|
$39.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $117.50 | Q:180 /30Days | $20.58 |
Browse Plan Formulary |
Affinity Medicare Ultimate (HMO SNP)
|
$39.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | Q:180 /30Days | $20.58 |
Browse Plan Formulary |
ArchCare Advantage (HMO SNP)
|
$39.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 1 |
All Formulary Drugs |
25% | 25% | Q:180 /30Days | $32.35 |
Browse Plan Formulary |
CenterLight Healthcare Direct Complete Plan (HMO SNP)
|
$39.30 |
$415* | No additional gap coverage, only the Donut Hole Discount | 1* |
Generic |
$5.75 | $17.25 | Q:360 /30Days | $15.56 |
Browse Plan Formulary |
Centers Plan for Dual Coverage Care (HMO SNP)
|
$39.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 1 |
All Formulary Drugs |
15% | 15% | Q:180 /30Days | $24.39 |
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 Nursing Home Care (HMO SNP)
|
$39.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 1 |
All Formulary Drugs |
25% | 25% | Q:180 /30Days | $24.25 |
Browse Plan Formulary |
Elderplan Advantage For Nursing Home Residents (HMO SNP)
|
$39.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 1 |
All Formulary Drugs |
25% | 25% | Q:180 /30Days | $7.37 |
Browse Plan Formulary |
Elderplan Plus Long Term Care (HMO SNP)
|
$39.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 1 |
All Formulary Drugs |
15% | 15% | Q:180 /30Days | $7.37 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO SNP)
|
$39.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 2 |
All Formulary Drugs |
$0.00 | $0.00 | Q:360 /30Days | $21.43 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO SNP)
|
$39.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 2 |
All Formulary Drugs |
$0.00 | $0.00 | Q:360 /30Days | $19.69 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO SNP)
|
$39.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 2 |
All Formulary Drugs |
$0.00 | $0.00 | Q:360 /30Days | $19.83 |
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)
|
$39.30 |
$415 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days | $32.08 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage Select (HMO SNP)
|
$39.30 |
$415 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:180 /30Days | $32.08 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO SNP)
|
$39.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 1 |
All Formulary Drugs |
$0.00 | $0.00 | Q:180 /30Days | $15.77 |
Browse Plan Formulary |
Healthfirst Increased Benefits Plan (HMO)
|
$39.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 1 |
All Formulary Drugs |
25% | 25% | Q:180 /30Days | $15.77 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO SNP)
|
$39.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 1 |
All Formulary Drugs |
$0.00 | $0.00 | Q:180 /30Days | $15.77 |
Browse Plan Formulary |
Longevity Health Plan (HMO SNP)
|
$39.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 1 |
All Formulary Drugs |
25% | n/a | Q:360 /30Days | $15.54 |
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 |
RiverSpring MAP (HMO SNP)
|
$39.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 1 |
All Formulary Drugs |
15% | 15% | Q:180 /30Days | $33.84 |
Browse Plan Formulary |
RiverSpring Star (HMO SNP)
|
$39.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 1 |
All Formulary Drugs |
25% | 25% | Q:180 /30Days | $33.84 |
Browse Plan Formulary |
Sunrise Advantage Plan I-SNP (HMO SNP)
|
$39.30 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | n/a | Q:360 /30Days | $16.05 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO SNP)
|
$39.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | $30.00 | Q:180 /30Days | $22.75 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
|
$46.00 |
$395* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$12.00 | $0.00 | Q:360 /30Days | $21.66 |
Browse Plan Formulary |
Sunrise Advantage Plan C-SNP (HMO SNP)
|
$49.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | n/a | Q:360 /30Days | $16.05 |
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)
|
$53.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:180 /30Days | $14.75 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$55.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$16.00 | $48.00 | Q:360 /30Days | $19.67 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$55.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$16.00 | $48.00 | Q:360 /30Days | $19.71 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$55.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$16.00 | $48.00 | Q:360 /30Days | $22.90 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$55.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$16.00 | $48.00 | Q:360 /30Days | $19.84 |
Browse Plan Formulary |
Humana Gold Plus H3533-023 (HMO)
|
$67.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $11.32 |
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 Go (HMO-POS)
|
$68.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$16.00 | $48.00 | Q:360 /30Days | $19.71 |
Browse Plan Formulary |
EmblemHealth VIP Go (HMO-POS)
|
$68.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$16.00 | $48.00 | Q:360 /30Days | $20.75 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$74.00 |
$195 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $136.00 | Q:180 /30Days | $40.63 |
Browse Plan Formulary |
HumanaChoice H5970-022 (PPO)
|
$95.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $11.32 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$119.50 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $30.00 | Q:360 /30Days | $19.84 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$119.50 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $30.00 | Q:360 /30Days | $22.90 |
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 |
EmblemHealth VIP Gold (HMO)
|
$119.50 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $30.00 | Q:360 /30Days | $19.71 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$119.50 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $30.00 | Q:360 /30Days | $19.67 |
Browse Plan Formulary |
Centers Plan for Medicaid Advantage Plus (HMO SNP)
|
$135.00 |
$415 | No additional gap coverage, only the Donut Hole Discount | 1 |
All Formulary Drugs |
$0.00 | $0.00 | Q:180 /30Days | $24.62 |
Browse Plan Formulary |
Sunrise Advantage Plan Gold (HMO SNP)
|
$175.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$9.00 | n/a | Q:360 /30Days | $16.05 |
Browse Plan Formulary |
HumanaChoice H5970-023 (PPO)
|
$199.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:360 /30Days | $11.32 |
Browse Plan Formulary |
MetroPlus Platinum (HMO)
|
$253.50 |
$415 | No additional gap coverage, only the Donut Hole Discount | 1 |
All Formulary Drugs |
25% | 25% | Q:180 /30Days | $7.76 |
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 Gold Plus (HMO)
|
$298.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $30.00 | Q:360 /30Days | $20.52 |
Browse Plan Formulary |