TELMISARTAN-HCTZ 80-12.5 MG TAB [Micardis HCT] (30 EA ) (NDC: 62332021030)
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. |
1* |
Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days | $23.88 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$195* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days | $28.56 |
Browse Plan Formulary |
Affinity Medicare Passport Essentials NYC (HMO)
|
$0.00 |
$295* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$1.00 | $2.50 | None | $62.27 |
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% | 0% | None | $58.11 |
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 | None | $61.88 |
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 |
2* |
Generic |
$18.00 | $54.00 | None | $61.64 |
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 | None | $72.96 |
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% | None | $89.56 |
Browse Plan Formulary |
HumanaChoice H5970-021 (PPO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:60 /30Days | $54.88 |
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% | None | $74.48 |
Browse Plan Formulary |
WellCare Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $68.70 |
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. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $68.13 |
Browse Plan Formulary |
WellCare Rx (HMO)
|
$14.70 |
$415* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $66.89 |
Browse Plan Formulary |
WellCare Rx (HMO)
|
$14.70 |
$415* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $69.73 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 1 (Regional PPO)
|
$16.00 |
$350* |
to be determined |
1* |
Preferred Generic |
$3.00 | $0.00 | Q:60 /30Days | $94.20 |
Browse Plan Formulary |
Humana Gold Plus H3533-021 (HMO)
|
$21.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:60 /30Days | $54.84 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 3 (Regional PPO)
|
$21.20 |
$275* |
to be determined |
1* |
Preferred Generic |
$3.00 | $0.00 | Q:60 /30Days | $94.20 |
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 |
1* |
Preferred Generic |
$3.00 | $0.00 | Q:60 /30Days | $95.85 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$28.50 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
All Formulary Drugs |
$0.00 | $0.00 | Q:60 /30Days | $94.30 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 4 (Regional PPO)
|
$33.60 |
$150* |
to be determined |
1* |
Preferred Generic |
$3.00 | $0.00 | Q:60 /30Days | $94.20 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$33.60 |
$415* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $68.21 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$33.60 |
$415* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $68.70 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 2 (HMO SNP)
|
$35.40 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
All Formulary Drugs |
25% | 25% | Q:60 /30Days | $95.64 |
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 |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:60 /30Days | $54.84 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 1 (PPO SNP)
|
$36.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
All Formulary Drugs |
25% | 25% | Q:60 /30Days | $95.65 |
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% | None | $93.15 |
Browse Plan Formulary |
Sunrise Advantage Plan (HMO)
|
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | n/a | None | $68.22 |
Browse Plan Formulary |
Affinity Medicare Solutions (HMO SNP)
|
$39.30 |
$415* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $61.87 |
Browse Plan Formulary |
Affinity Medicare Ultimate (HMO SNP)
|
$39.30 |
$415* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $61.87 |
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 |
ArchCare Advantage (HMO SNP)
|
$39.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
All Formulary Drugs |
25% | 25% | None | $93.64 |
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 | $67.32 |
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% | None | $58.11 |
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% | None | $58.11 |
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 | None | $61.42 |
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 | None | $60.69 |
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 |
2 |
All Formulary Drugs |
$0.00 | $0.00 | None | $62.29 |
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 | None | $77.15 |
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 | None | $77.15 |
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 | None | $89.55 |
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% | None | $89.55 |
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 | None | $89.55 |
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 | $67.10 |
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% | None | $74.48 |
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% | None | $74.48 |
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 | None | $68.22 |
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 | None | $54.77 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
|
$46.00 |
$395* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$3.00 | $0.00 | Q:60 /30Days | $95.85 |
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 C-SNP (HMO SNP)
|
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | n/a | None | $68.22 |
Browse Plan Formulary |
WellCare Preferred (HMO)
|
$53.00 |
$0 |
Yes, this drug has Gap Coverage. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $68.34 |
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 | None | $62.31 |
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 | None | $61.27 |
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 | None | $60.70 |
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 | None | $61.57 |
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 |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:60 /30Days | $54.92 |
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 | None | $60.70 |
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 | None | $62.04 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$74.00 |
$195* |
Yes, but No Gap Coverage for this drug. |
1* |
Preferred Generic |
$2.00 | $0.00 | Q:30 /30Days | $26.54 |
Browse Plan Formulary |
HumanaChoice H5970-022 (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:60 /30Days | $54.88 |
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 | None | $62.31 |
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 | None | $61.27 |
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 | None | $60.70 |
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 | None | $61.57 |
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 | None | $68.22 |
Browse Plan Formulary |
MetroPlus Platinum (HMO)
|
$253.50 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
All Formulary Drugs |
25% | 25% | None | $93.15 |
Browse Plan Formulary |
EmblemHealth VIP Gold Plus (HMO)
|
$298.00 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $30.00 | None | $61.88 |
Browse Plan Formulary |