HYDROXYZINE HCL 10 MG TABLET (100.000 EA ) (NDC: 10702001001)
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 |
AARP MedicareComplete Mosaic (HMO)
|
$0.00 |
$295 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $64.38 |
Browse Plan Formulary |
Aetna Medicare Elite Plan (PPO)
|
$0.00 |
$245 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $95.28 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $98.11 |
Browse Plan Formulary |
Affinity Medicare Passport Essentials NYC (HMO)
|
$0.00 |
$295* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$12.00 | $30.00 | P | $46.92 |
Browse Plan Formulary |
Bright Advantage (HMO)
|
$0.00 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $30.00 | P | $23.62 |
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 |
Bright Advantage Flex (PPO)
|
$0.00 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $30.00 | P | $23.62 |
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% | P | $38.75 |
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 | P | $38.63 |
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 | $6.32 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $46.62 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $45.74 |
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 |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $44.13 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $47.06 |
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 | None | $46.29 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P | $48.14 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P | $55.00 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P | $44.11 |
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 Select (HMO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P | $52.10 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $10.00 | P | $15.86 |
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 | $15.87 |
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 | $17.80 |
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 | None | $17.80 |
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% | P | $20.23 |
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. |
1 |
Generic Drugs |
0% | 0% | P | $80.68 |
Browse Plan Formulary |
SWH Whole Health FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | 0% | P | $53.38 |
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% | P | $29.33 |
Browse Plan Formulary |
WellCare Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$15.00 | $0.00 | P | $18.96 |
Browse Plan Formulary |
WellCare Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$15.00 | $0.00 | P | $19.87 |
Browse Plan Formulary |
WellCare Rx (HMO)
|
$14.70 |
$415 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | P | $19.25 |
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 Rx (HMO)
|
$14.70 |
$415 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | P | $20.09 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 1 (Regional PPO)
|
$16.00 |
$350 |
to be determined |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $64.84 |
Browse Plan Formulary |
AgeWell New York LiveWell (HMO)
|
$19.00 |
$275* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$3.00 | $0.00 | P | $33.63 |
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 | None | $17.80 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 3 (Regional PPO)
|
$21.20 |
$275 |
to be determined |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $64.84 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$26.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $65.00 |
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 |
UnitedHealthcare Dual Complete (HMO SNP)
|
$28.50 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
3 |
All Formulary Drugs |
$0.00 | $0.00 | None | $64.74 |
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 | P | $6.55 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 4 (Regional PPO)
|
$33.60 |
$150 |
to be determined |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $64.84 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$33.60 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$1.00 | $0.00 | P | $19.90 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$33.60 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$1.00 | $0.00 | P | $18.96 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 2 (HMO SNP)
|
$35.40 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
3 |
All Formulary Drugs |
25% | 25% | None | $67.52 |
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 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 | None | $17.80 |
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 | P | $6.43 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 1 (PPO SNP)
|
$36.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
3 |
All Formulary Drugs |
25% | 25% | None | $67.57 |
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 | P | $6.55 |
Browse Plan Formulary |
Bright Advantage Assist (HMO)
|
$39.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
2 |
All Formulary Drugs |
25% | 25% | P | $23.62 |
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% | P | $8.94 |
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 |
1 |
Preferred Generic |
$4.00 | n/a | None | $31.85 |
Browse Plan Formulary |
Affinity Medicare Solutions (HMO SNP)
|
$39.30 |
$415* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$7.00 | $17.50 | P | $46.27 |
Browse Plan Formulary |
Affinity Medicare Ultimate (HMO SNP)
|
$39.30 |
$415* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$6.00 | $15.00 | P | $46.27 |
Browse Plan Formulary |
AgeWell New York Advantage Plus (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
All Formulary Drugs |
$0.00 | $0.00 | P | $33.63 |
Browse Plan Formulary |
AgeWell New York CareWell (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
All Formulary Drugs |
25% | 25% | P | $34.59 |
Browse Plan Formulary |
AgeWell New York FeelWell (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
All Formulary Drugs |
$0.00 | $0.00 | P | $33.63 |
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 |
ArchCare Advantage (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
All Formulary Drugs |
25% | 25% | P | $63.96 |
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 | None | $30.07 |
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% | P | $38.74 |
Browse Plan Formulary |
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% | P | $38.10 |
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 | $6.20 |
Browse Plan Formulary |
Elderplan Extra Help (HMO)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
All Formulary Drugs |
25% | 25% | P | $6.44 |
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 For Medicaid Beneficiaries (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
All Formulary Drugs |
15% | 15% | P | $6.32 |
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% | P | $6.27 |
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 | None | $45.19 |
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 | None | $45.72 |
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 | None | $47.04 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage (HMO SNP)
|
$39.30 |
$415 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $55.92 |
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 Select (HMO SNP)
|
$39.30 |
$415 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $55.92 |
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 | P | $15.86 |
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 | $15.86 |
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 | $15.86 |
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% | P | $30.99 |
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 | P | $30.99 |
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 |
Longevity Health Plan (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
All Formulary Drugs |
25% | n/a | None | $30.02 |
Browse Plan Formulary |
RiverSpring MAP (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
All Formulary Drugs |
15% | 15% | P | $80.68 |
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 | $80.68 |
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% | P | $52.73 |
Browse Plan Formulary |
Sunrise Advantage Plan I-SNP (HMO SNP)
|
$39.30 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$4.00 | n/a | None | $31.85 |
Browse Plan Formulary |
VillageCareMAX Medicare Health Advantage (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
All Formulary Drugs |
15% | 15% | P | $27.74 |
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 |
VNSNY CHOICE Total (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$4.00 | $12.00 | P | $29.63 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
|
$46.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $65.00 |
Browse Plan Formulary |
Sunrise Advantage Plan C-SNP (HMO SNP)
|
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$4.00 | n/a | None | $31.85 |
Browse Plan Formulary |
WellCare Preferred (HMO)
|
$53.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$15.00 | $0.00 | P | $19.75 |
Browse Plan Formulary |
Bright Advantage Plus (HMO)
|
$55.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $0.00 | P | $23.62 |
Browse Plan Formulary |
VillageCareMAX Medicare Total Advantage (HMO SNP)
|
$60.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
All Formulary Drugs |
$0.00 | $0.00 | P | $27.74 |
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 |
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 | None | $17.80 |
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 | None | $45.74 |
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 | None | $46.38 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$74.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $95.20 |
Browse Plan Formulary |
AgeWell New York PlanWell (HMO)
|
$86.00 |
$250* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$0.00 | $0.00 | P | $33.63 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$88.50 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $46.62 |
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 |
EmblemHealth VIP Gold (HMO)
|
$88.50 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $45.74 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$88.50 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $44.13 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$88.50 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $47.06 |
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 | None | $17.80 |
Browse Plan Formulary |
Empire MediBlue Choice (HMO-POS)
|
$103.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P | $48.14 |
Browse Plan Formulary |
Bright Advantage Flex Plus (PPO)
|
$110.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $0.00 | P | $23.62 |
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 |
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 | P | $39.22 |
Browse Plan Formulary |
Sunrise Advantage Plan Gold (HMO SNP)
|
$175.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | n/a | None | $31.85 |
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 | None | $17.80 |
Browse Plan Formulary |
MetroPlus Platinum (HMO)
|
$253.50 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
All Formulary Drugs |
25% | 25% | P | $8.94 |
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 | None | $46.29 |
Browse Plan Formulary |