FYCOMPA 10 MG TABLET (30 EA ) (NDC: 62856028030)
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. |
5 |
Specialty Tier |
28% | n/a | P Q:30 /30Days | $979.87 |
Browse Plan Formulary |
Affinity Medicare Passport Essentials (HMO)
|
$0.00 |
$295 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
27% | n/a | P Q:30 /30Days | $964.50 |
Browse Plan Formulary |
Centers Plan for Medicare Advantage Care (HMO)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
25% | n/a | S | $971.27 |
Browse Plan Formulary |
Elderplan FIDA Total Care (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | 0% | P Q:30 /30Days | $956.93 |
Browse Plan Formulary |
EmblemHealth VIP Part B Saver (HMO)
|
$0.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $941.07 |
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 Value (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $952.80 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
26% | 26% | P Q:30 /30Days | $973.39 |
Browse Plan Formulary |
Healthfirst AbsoluteCare FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | 0% | P Q:30 /30Days | $945.17 |
Browse Plan Formulary |
Humana Gold Plus H3533-027 (HMO)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,008.54 |
Browse Plan Formulary |
HumanaChoice H5970-021 (PPO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
26% | n/a | P Q:30 /30Days | $1,008.54 |
Browse Plan Formulary |
PHP Care Complete FIDA-IDD Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | 0% | S Q:30 /30Days | $949.01 |
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 |
RiverSpring FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | 0% | P | $961.45 |
Browse Plan Formulary |
VNSNY CHOICE FIDA Complete (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | 0% | S | $961.75 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 1 (Regional PPO)
|
$16.00 |
$350 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $1,015.22 |
Browse Plan Formulary |
AgeWell New York LiveWell (HMO)
|
$19.00 |
$275 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | None | $980.73 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 3 (Regional PPO)
|
$21.20 |
$275 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $1,015.22 |
Browse Plan Formulary |
Humana Gold Plus H3533-010 (HMO)
|
$27.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | P Q:30 /30Days | $1,008.54 |
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 |
UnitedHealthcare Dual Complete (HMO SNP)
|
$28.50 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
All Formulary Drugs |
$0.00 | $0.00 | None | $1,014.24 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 4 (Regional PPO)
|
$33.60 |
$150 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $1,015.22 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$33.60 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $970.51 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$33.60 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $970.51 |
Browse Plan Formulary |
WellCare Choice (HMO)
|
$35.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $970.51 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 2 (HMO SNP)
|
$35.40 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
All Formulary Drugs |
25% | 25% | None | $1,019.13 |
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 Dual Advantage Flex (HMO SNP)
|
$36.10 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $943.14 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 1 (PPO SNP)
|
$36.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
All Formulary Drugs |
25% | 25% | None | $1,019.23 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$37.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
29% | n/a | P Q:30 /30Days | $979.77 |
Browse Plan Formulary |
Sunrise Advantage Plan (HMO)
|
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | n/a | P | $973.18 |
Browse Plan Formulary |
Affinity Medicare Solutions (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $941.30 |
Browse Plan Formulary |
Affinity Medicare Ultimate (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $941.30 |
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 |
AgeWell New York Advantage Plus (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
All Formulary Drugs |
$0.00 | $0.00 | None | $980.73 |
Browse Plan Formulary |
AgeWell New York CareWell (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
All Formulary Drugs |
25% | 25% | None | $980.00 |
Browse Plan Formulary |
AgeWell New York FeelWell (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
All Formulary Drugs |
$0.00 | $0.00 | None | $980.73 |
Browse Plan Formulary |
CenterLight Healthcare Direct Complete Plan (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Brand |
25% | 25% | P | $968.83 |
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% | P Q:30 /30Days | $956.93 |
Browse Plan Formulary |
Elderplan For Medicaid Beneficiaries (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
All Formulary Drugs |
15% | 15% | P Q:30 /30Days | $956.93 |
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)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
All Formulary Drugs |
15% | 15% | P Q:30 /30Days | $956.93 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
All Formulary Drugs |
$0.00 | $0.00 | P | $963.55 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
All Formulary Drugs |
$0.00 | $0.00 | P | $924.23 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
All Formulary Drugs |
$0.00 | $0.00 | P | $924.64 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage (HMO SNP)
|
$39.30 |
$415 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $949.62 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage Select (HMO SNP)
|
$39.30 |
$415 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $949.62 |
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 CompleteCare (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
All Formulary Drugs |
$0.00 | $0.00 | P Q:30 /30Days | $973.39 |
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% | P Q:30 /30Days | $973.39 |
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 | P Q:30 /30Days | $973.39 |
Browse Plan Formulary |
Integra Harmony Plan (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
All Formulary Drugs |
15% | 15% | S Q:30 /30Days | $994.40 |
Browse Plan Formulary |
Integra Synergy Plan (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
All Formulary Drugs |
$0.00 | $0.00 | S Q:30 /30Days | $994.40 |
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 | P | $969.74 |
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% | P | $961.45 |
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% | P | $961.45 |
Browse Plan Formulary |
Senior Whole Health of New York NHC (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
All Formulary Drugs |
15% | 15% | None | $947.81 |
Browse Plan Formulary |
Sunrise Advantage Plan I-SNP (HMO SNP)
|
$39.30 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | n/a | P | $973.18 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $963.82 |
Browse Plan Formulary |
Empire MediBlue Select (HMO)
|
$46.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$94.00 | $282.00 | Q:30 /30Days | $1,004.56 |
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 Plus (HMO)
|
$49.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $1,004.56 |
Browse Plan Formulary |
Sunrise Advantage Plan C-SNP (HMO SNP)
|
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | n/a | P | $973.18 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$55.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $924.40 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$55.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $930.80 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$55.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $924.27 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$55.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $1,004.59 |
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 |
Empire MediBlue Choice (HMO-POS)
|
$66.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:30 /30Days | $1,004.56 |
Browse Plan Formulary |
Humana Gold Plus H3533-023 (HMO)
|
$67.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,008.54 |
Browse Plan Formulary |
EmblemHealth VIP Go (HMO-POS)
|
$68.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $924.27 |
Browse Plan Formulary |
EmblemHealth VIP Go (HMO-POS)
|
$68.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $943.44 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$74.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
29% | n/a | P Q:30 /30Days | $979.65 |
Browse Plan Formulary |
AgeWell New York PlanWell (HMO)
|
$86.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | None | $980.73 |
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 |
HumanaChoice H5970-022 (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,008.54 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$119.50 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $924.40 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$119.50 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $930.80 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$119.50 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $924.27 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$119.50 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $1,004.59 |
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 | S | $969.58 |
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 Gold (HMO SNP)
|
$175.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | n/a | P | $973.18 |
Browse Plan Formulary |
HumanaChoice H5970-023 (PPO)
|
$199.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,008.54 |
Browse Plan Formulary |
EmblemHealth VIP Gold Plus (HMO)
|
$298.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $941.07 |
Browse Plan Formulary |