XELJANZ XR 11 MG TABLET (NDC: 00069050130)
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 | $4,732.44 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$195 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
29% | n/a | P Q:30 /30Days | $4,732.44 |
Browse Plan Formulary |
Affinity Medicare Passport Essentials NYC (HMO)
|
$0.00 |
$295 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
27% | n/a | P | $4,324.87 |
Browse Plan Formulary |
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:30 /30Days | $4,515.92 |
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:30 /30Days | $4,517.79 |
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 |
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 | $4,463.48 |
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:30 /30Days | $4,323.69 |
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:30 /30Days | $4,349.26 |
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:30 /30Days | $4,394.22 |
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:30 /30Days | $4,338.61 |
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:30 /30Days | $4,334.55 |
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 |
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 | $4,541.20 |
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 | $4,409.47 |
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 | $4,495.76 |
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:30 /30Days | $4,453.86 |
Browse Plan Formulary |
WellCare Choice (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $4,527.76 |
Browse Plan Formulary |
WellCare Choice (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $4,527.76 |
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 |
WellCare Rx (HMO)
|
$14.70 |
$415 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $4,527.76 |
Browse Plan Formulary |
WellCare Rx (HMO)
|
$14.70 |
$415 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $4,527.76 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 1 (Regional PPO)
|
$16.00 |
$350 | to be determined | 5 |
Specialty Tier |
26% | 26% | P Q:30 /30Days | $4,775.91 |
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 | $4,554.75 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 3 (Regional PPO)
|
$21.20 |
$275 | to be determined | 5 |
Specialty Tier |
27% | 27% | P Q:30 /30Days | $4,775.91 |
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:30 /30Days | $4,786.44 |
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 |
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:30 /30Days | $4,776.70 |
Browse Plan Formulary |
Fidelis Medicaid Advantage Plus (HMO SNP)
|
$29.20 |
$415 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $4,400.49 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 4 (Regional PPO)
|
$33.60 |
$150 | to be determined | 5 |
Specialty Tier |
30% | 30% | P Q:30 /30Days | $4,775.91 |
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 | $4,527.76 |
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 | $4,527.76 |
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:30 /30Days | $4,777.18 |
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 | $4,399.37 |
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:30 /30Days | $4,777.32 |
Browse Plan Formulary |
Fidelis Dual Advantage (HMO SNP)
|
$38.90 |
$415 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $4,399.70 |
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 Q:30 /30Days | $4,409.48 |
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 | $4,333.89 |
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 | $4,333.89 |
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 | 5 |
All Formulary Drugs |
$0.00 | $0.00 | P | $4,554.75 |
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 | $4,556.28 |
Browse Plan Formulary |
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 | $4,554.75 |
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% | P Q:30 /30Days | $4,424.45 |
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:30 /30Days | $4,515.92 |
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:30 /30Days | $4,514.61 |
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 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 | $4,463.48 |
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 Q:30 /30Days | $4,463.48 |
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 | $4,463.48 |
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 Q:30 /30Days | $4,463.48 |
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:30 /30Days | $4,397.11 |
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:30 /30Days | $4,342.57 |
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 |
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:30 /30Days | $4,324.15 |
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 | P Q:30 /30Days | $4,541.20 |
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 | $4,541.20 |
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 | $4,541.20 |
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 | $4,495.76 |
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 | $4,495.76 |
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 |
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:30 /30Days | $4,350.42 |
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:30 /30Days | $4,459.67 |
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:30 /30Days | $4,786.44 |
Browse Plan Formulary |
WellCare Preferred (HMO)
|
$53.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $4,527.76 |
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:30 /30Days | $4,331.64 |
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:30 /30Days | $4,328.71 |
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 |
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:30 /30Days | $4,350.42 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$67.00 |
$195 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
29% | n/a | P Q:30 /30Days | $4,732.44 |
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:30 /30Days | $4,394.22 |
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:30 /30Days | $4,331.02 |
Browse Plan Formulary |
AgeWell New York PlanWell (HMO)
|
$86.00 |
$250 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
28% | 28% | P | $4,554.75 |
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:30 /30Days | $4,323.69 |
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 Gold (HMO)
|
$88.50 |
$200 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
29% | n/a | P Q:30 /30Days | $4,349.26 |
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:30 /30Days | $4,394.22 |
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:30 /30Days | $4,338.61 |
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 | P Q:30 /30Days | $4,520.08 |
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 Q:30 /30Days | $4,409.48 |
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:30 /30Days | $4,334.55 |
Browse Plan Formulary |