REPATHA 140 MG/ML SURECLICK (1.000 ML ) (NDC: 55513076002)
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 |
Centers Plan for FIDA Care Complete (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | 0% | P Q:3 /28Days | $1,122.89 |
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 | P Q:3 /28Days | $1,124.29 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | P Q:3 /28Days | $1,089.17 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | P Q:3 /28Days | $1,082.84 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | P Q:3 /28Days | $1,073.11 |
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 |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | P Q:3 /28Days | $1,085.33 |
Browse Plan Formulary |
EmblemHealth VIP Part B Saver (HMO)
|
$0.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:3 /28Days | $1,076.56 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
26% | n/a | P Q:3 /28Days | $1,073.63 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
26% | n/a | P Q:3 /28Days | $1,069.11 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
26% | n/a | P Q:3 /28Days | $1,082.97 |
Browse Plan Formulary |
Empire MediBlue Select (HMO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
26% | n/a | P Q:3 /28Days | $1,073.79 |
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 |
5 |
Specialty Tier |
25% | n/a | P Q:3 /28Days | $1,173.56 |
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:3 /28Days | $1,173.56 |
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% | P | $1,101.58 |
Browse Plan Formulary |
RiverSpring FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | 0% | P | $1,119.21 |
Browse Plan Formulary |
SWH Whole Health FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | 0% | P Q:3 /28Days | $1,073.13 |
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% | P Q:3 /28Days | $1,111.23 |
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 |
UnitedHealthcare MedicareComplete Choice Plan 1 (Regional PPO)
|
$16.00 |
$350 |
to be determined |
5 |
Specialty Tier |
26% | 26% | P Q:3 /28Days | $1,192.93 |
Browse Plan Formulary |
AgeWell New York LiveWell (HMO)
|
$19.00 |
$275 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
27% | 27% | P | $1,136.10 |
Browse Plan Formulary |
Humana Gold Plus H3533-021 (HMO)
|
$21.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | P Q:3 /28Days | $1,173.56 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 3 (Regional PPO)
|
$21.20 |
$275 |
to be determined |
5 |
Specialty Tier |
27% | 27% | P Q:3 /28Days | $1,192.93 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$26.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | P Q:3 /28Days | $1,194.15 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$28.50 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
5 |
All Formulary Drugs |
$0.00 | $0.00 | P Q:3 /28Days | $1,193.12 |
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 MedicareComplete Choice Plan 4 (Regional PPO)
|
$33.60 |
$150 |
to be determined |
5 |
Specialty Tier |
30% | 30% | P Q:3 /28Days | $1,192.93 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 2 (HMO SNP)
|
$35.40 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
5 |
All Formulary Drugs |
25% | 25% | P Q:3 /28Days | $1,193.72 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H3533-004 (HMO SNP)
|
$35.70 |
$385 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:3 /28Days | $1,173.56 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 1 (PPO SNP)
|
$36.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
5 |
All Formulary Drugs |
25% | 25% | P Q:3 /28Days | $1,193.72 |
Browse Plan Formulary |
AgeWell New York Advantage Plus (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
5 |
All Formulary Drugs |
$0.00 | $0.00 | P | $1,136.10 |
Browse Plan Formulary |
AgeWell New York CareWell (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
5 |
All Formulary Drugs |
25% | 25% | P | $1,136.16 |
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)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
5 |
All Formulary Drugs |
$0.00 | $0.00 | P | $1,136.10 |
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 Q:2 /28Days | $1,117.40 |
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 Q:3 /28Days | $1,122.89 |
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 Q:3 /28Days | $1,123.58 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
5 |
All Formulary Drugs |
$0.00 | $0.00 | P Q:3 /28Days | $1,073.10 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
5 |
All Formulary Drugs |
$0.00 | $0.00 | P Q:3 /28Days | $1,084.45 |
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 |
EmblemHealth VIP Dual (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
5 |
All Formulary Drugs |
$0.00 | $0.00 | P Q:3 /28Days | $1,089.16 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage (HMO SNP)
|
$39.30 |
$415 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P Q:3 /28Days | $1,076.24 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage Select (HMO SNP)
|
$39.30 |
$415 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P Q:3 /28Days | $1,076.24 |
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 | $1,136.09 |
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 | $1,136.09 |
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 Q:2 /28Days | $1,117.35 |
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 | $1,119.21 |
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 | $1,119.21 |
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 Q:3 /28Days | $1,075.51 |
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 Q:3 /28Days | $1,085.16 |
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 | P Q:3 /28Days | $1,111.99 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
|
$46.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | P Q:3 /28Days | $1,194.15 |
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 |
EmblemHealth VIP Rx Saver (HMO)
|
$55.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:3 /28Days | $1,085.20 |
Browse Plan Formulary |
EmblemHealth VIP Rx Saver (HMO)
|
$55.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:3 /28Days | $1,073.66 |
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 Q:3 /28Days | $1,085.16 |
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:3 /28Days | $1,173.56 |
Browse Plan Formulary |
EmblemHealth VIP Go (HMO-POS)
|
$68.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | P Q:3 /28Days | $1,089.17 |
Browse Plan Formulary |
EmblemHealth VIP Go (HMO-POS)
|
$68.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | P Q:3 /28Days | $1,076.03 |
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 |
AgeWell New York PlanWell (HMO)
|
$86.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | 28% | P | $1,136.10 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$88.50 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | P Q:3 /28Days | $1,089.17 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$88.50 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | P Q:3 /28Days | $1,082.84 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$88.50 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | P Q:3 /28Days | $1,073.11 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$88.50 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | P Q:3 /28Days | $1,085.33 |
Browse Plan Formulary |
HumanaChoice H5970-022 (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:3 /28Days | $1,173.56 |
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 |
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 Q:3 /28Days | $1,123.88 |
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:3 /28Days | $1,173.56 |
Browse Plan Formulary |
EmblemHealth VIP Gold Plus (HMO)
|
$298.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | P Q:3 /28Days | $1,076.56 |
Browse Plan Formulary |