LEVOTHYROXINE 25 MCG TABLET (1000.000 EA ) (NDC: 00378180010)
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 | None | $8.34 |
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 | None | $9.60 |
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 | None | $8.27 |
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% | None | $11.10 |
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 | None | $11.10 |
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. | 1 |
Generic Drugs |
0% | 0% | None | $8.44 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $8.61 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $8.88 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $9.26 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $8.45 |
Browse Plan Formulary |
EmblemHealth VIP Part B Saver (HMO)
|
$0.00 |
$415* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $8.71 |
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 |
Empire MediBlue Plus (HMO)
|
$0.00 |
$350* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$3.00 | $9.00 | None | $7.92 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$350* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$3.00 | $9.00 | None | $7.97 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$350* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$3.00 | $9.00 | None | $7.96 |
Browse Plan Formulary |
Empire MediBlue Select (HMO)
|
$0.00 |
$350* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$3.00 | $9.00 | None | $7.97 |
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 | None | $10.36 |
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 | $10.36 |
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 | 1* |
Preferred Generic |
$6.00 | $0.00 | None | $10.28 |
Browse Plan Formulary |
HumanaChoice H5970-021 (PPO)
|
$0.00 |
$350* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$2.00 | $0.00 | None | $10.28 |
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% | None | $9.47 |
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 | $7.68 |
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% | None | $8.33 |
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% | None | $9.16 |
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 |
WellCare Choice (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $7.95 |
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 | $8.08 |
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 | $7.91 |
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 | $8.16 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 1 (Regional PPO)
|
$16.00 |
$350* | to be determined | 1* |
Preferred Generic |
$3.00 | $0.00 | None | $9.55 |
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 | None | $10.45 |
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 |
Humana Gold Plus H3533-021 (HMO)
|
$21.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$2.00 | $0.00 | None | $10.29 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 3 (Regional PPO)
|
$21.20 |
$275* | to be determined | 1* |
Preferred Generic |
$3.00 | $0.00 | None | $9.55 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$26.00 |
$415* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$3.00 | $0.00 | None | $9.58 |
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 | None | $9.58 |
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 | None | $6.30 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice Plan 4 (Regional PPO)
|
$33.60 |
$150* | to be determined | 1* |
Preferred Generic |
$3.00 | $0.00 | None | $9.55 |
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 |
WellCare Access (HMO SNP)
|
$33.60 |
$415* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $8.18 |
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 | $7.95 |
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% | None | $9.55 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H3533-004 (HMO SNP)
|
$35.70 |
$385* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $10.29 |
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 | None | $6.12 |
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% | None | $9.55 |
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 |
Fidelis Dual Advantage (HMO SNP)
|
$38.90 |
$415 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $40.00 | None | $6.25 |
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 | $7.45 |
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 | None | $8.56 |
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 | None | $8.56 |
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 | None | $10.45 |
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% | None | $10.35 |
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 |
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 | None | $10.45 |
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% | None | $7.61 |
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 | $11.35 |
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% | None | $11.10 |
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% | None | $11.10 |
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% | None | $8.44 |
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 Extra Help (HMO)
|
$39.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 1 |
All Formulary Drugs |
25% | 25% | None | $8.44 |
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% | None | $8.44 |
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 | $8.44 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO SNP)
|
$39.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 1 |
All Formulary Drugs |
$0.00 | $0.00 | None | $8.92 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO SNP)
|
$39.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 1 |
All Formulary Drugs |
$0.00 | $0.00 | None | $8.76 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO SNP)
|
$39.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 1 |
All Formulary Drugs |
$0.00 | $0.00 | None | $8.25 |
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 |
Empire MediBlue Dual Advantage (HMO SNP)
|
$39.30 |
$415* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $8.33 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage Select (HMO SNP)
|
$39.30 |
$415* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $8.33 |
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 | $10.36 |
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 | $10.36 |
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 | $10.36 |
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% | None | $11.42 |
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 |
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 | None | $11.42 |
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 | None | $11.35 |
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 | $7.68 |
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% | None | $7.68 |
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% | None | $8.65 |
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% | None | $9.80 |
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 | None | $9.06 |
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 | None | $9.58 |
Browse Plan Formulary |
WellCare Preferred (HMO)
|
$53.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $8.14 |
Browse Plan Formulary |
EmblemHealth VIP Rx Saver (HMO)
|
$55.00 |
$395* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $8.69 |
Browse Plan Formulary |
EmblemHealth VIP Rx Saver (HMO)
|
$55.00 |
$395* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $8.34 |
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 | None | $9.80 |
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 |
Aetna Medicare Premier Plan (PPO)
|
$67.00 |
$195* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$2.00 | $0.00 | None | $8.22 |
Browse Plan Formulary |
Humana Gold Plus H3533-023 (HMO)
|
$67.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $10.28 |
Browse Plan Formulary |
EmblemHealth VIP Go (HMO-POS)
|
$68.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $8.88 |
Browse Plan Formulary |
EmblemHealth VIP Go (HMO-POS)
|
$68.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $8.69 |
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 | None | $10.45 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$88.50 |
$200* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $8.61 |
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 |
EmblemHealth VIP Gold (HMO)
|
$88.50 |
$200* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $8.88 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$88.50 |
$200* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $9.26 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$88.50 |
$200* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $8.45 |
Browse Plan Formulary |
HumanaChoice H5970-022 (PPO)
|
$95.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $10.28 |
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 | None | $11.09 |
Browse Plan Formulary |
HumanaChoice H5970-023 (PPO)
|
$199.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$5.00 | $0.00 | None | $10.28 |
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 |
MetroPlus Platinum (HMO)
|
$253.50 |
$415 | No additional gap coverage, only the Donut Hole Discount | 1 |
All Formulary Drugs |
25% | 25% | None | $7.45 |
Browse Plan Formulary |
EmblemHealth VIP Gold Plus (HMO)
|
$298.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $8.71 |
Browse Plan Formulary |