TETRABENAZINE 12.5 MG TABLET [XENAZINE] (112 EA ) (NDC: 47335027723)
2020 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 Medicare Advantage Mosaic (HMO)
|
$0.00 |
$250 |
No |
5 |
Tier 5 |
28% | 28% | P Q:90 /30Days | $1,636.50 |
Browse Plan Formulary |
AARP Medicare Advantage Mosaic Choice (PPO)
|
$0.00 |
$250 |
No |
5 |
Tier 5 |
28% | 28% | P Q:90 /30Days | $1,636.50 |
Browse Plan Formulary |
Aetna Medicare Elite Plan (PPO)
|
$0.00 |
$300 |
No |
5 |
Tier 5 |
27% | n/a | P Q:90 /30Days | $659.10 |
Browse Plan Formulary |
Bright Advantage (HMO)
|
$0.00 |
$95 |
No |
5 |
Tier 5 |
31% | n/a | P Q:240 /30Days | $1,661.40 |
Browse Plan Formulary |
Bright Advantage Choice (HMO)
|
$0.00 |
$295 |
No |
5 |
Tier 5 |
27% | n/a | P Q:240 /30Days | $1,661.40 |
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 |
$195 |
No |
5 |
Tier 5 |
29% | n/a | P Q:240 /30Days | $1,661.40 |
Browse Plan Formulary |
Centers Plan for Medicare Advantage Care (HMO)
|
$0.00 |
$395 |
No |
5 |
Tier 5 |
25% | n/a | P Q:112 /28Days | $608.10 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$295 |
No |
5 |
Tier 5 |
27% | n/a | P | $1,455.00 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$295 |
No |
5 |
Tier 5 |
27% | n/a | P | $1,868.10 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$295 |
No |
5 |
Tier 5 |
27% | n/a | P | $1,439.10 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$295 |
No |
5 |
Tier 5 |
27% | n/a | P | $1,635.60 |
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 Part B Saver (HMO)
|
$0.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P | $1,629.60 |
Browse Plan Formulary |
EmblemHealth VIP Value (HMO)
|
$0.00 |
$295 |
No |
5 |
Tier 5 |
27% | n/a | P | $1,667.10 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$350 |
No |
5 |
Tier 5 |
26% | n/a | P Q:240 /30Days | $1,771.20 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$350 |
No |
5 |
Tier 5 |
26% | n/a | P Q:240 /30Days | $1,771.20 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$350 |
No |
5 |
Tier 5 |
26% | n/a | P Q:240 /30Days | $1,771.20 |
Browse Plan Formulary |
Empire MediBlue Select (HMO)
|
$0.00 |
$350 |
No |
5 |
Tier 5 |
26% | n/a | P Q:240 /30Days | $1,771.20 |
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 |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$350 |
No |
5 |
Tier 5 |
26% | 26% | P Q:240 /30Days | $1,771.20 |
Browse Plan Formulary |
Humana Gold Plus H3533-027 (HMO)
|
$0.00 |
$400 |
No |
5 |
Tier 5 |
25% | n/a | P Q:240 /30Days | $392.40 |
Browse Plan Formulary |
HumanaChoice H5970-021 (PPO)
|
$0.00 |
$350 |
No |
5 |
Tier 5 |
26% | n/a | P Q:240 /30Days | $392.40 |
Browse Plan Formulary |
PHP Care Complete FIDA-IDD Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
1 |
Tier 1 |
0% | 0% | P | $230.40 |
Browse Plan Formulary |
WellCare Choice (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:240 /30Days | $512.40 |
Browse Plan Formulary |
WellCare Element (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:240 /30Days | $482.70 |
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 Today's Options Advantage Plus 550B (PPO)
|
$10.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:240 /30Days | $484.20 |
Browse Plan Formulary |
WellCare Rx (HMO)
|
$13.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:240 /30Days | $583.50 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO)
|
$16.00 |
$300 |
No |
5 |
Tier 5 |
27% | 27% | P Q:90 /30Days | $1,605.30 |
Browse Plan Formulary |
Fidelis Medicaid Advantage Plus (HMO D-SNP)
|
$17.40 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:240 /30Days | $1,771.20 |
Browse Plan Formulary |
Fidelis Medicaid Advantage Plus (HMO D-SNP)
|
$17.40 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:240 /30Days | $1,771.20 |
Browse Plan Formulary |
Humana Gold Plus H3533-021 (HMO)
|
$20.00 |
$200 |
No |
5 |
Tier 5 |
29% | n/a | P Q:240 /30Days | $392.40 |
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 Assisted Living Plan (PPO I-SNP)
|
$20.30 |
$200 |
No |
5 |
Tier 5 |
29% | 29% | P Q:90 /30Days | $1,640.70 |
Browse Plan Formulary |
Empire MediBlue Extra (HMO)
|
$21.70 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:240 /30Days | $1,771.20 |
Browse Plan Formulary |
Elderplan Extra Help (HMO)
|
$23.80 |
$435 |
No |
5 |
Tier 5 |
25% | 25% | P Q:240 /30Days | $1,771.20 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO D-SNP)
|
$27.10 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:240 /30Days | $1,766.40 |
Browse Plan Formulary |
WellCare Access (HMO D-SNP)
|
$27.40 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:240 /30Days | $507.60 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 2 (HMO)
|
$29.00 |
$415 |
No |
5 |
Tier 5 |
25% | 25% | P Q:90 /30Days | $1,642.80 |
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 |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$29.60 |
$435 |
No |
5 |
Tier 5 |
$0.00 | $0.00 | P Q:90 /30Days | $1,604.70 |
Browse Plan Formulary |
Elderplan For Medicaid Beneficiaries (HMO D-SNP)
|
$31.70 |
$435 |
No |
1 |
Tier 1 |
15% | 15% | P Q:240 /30Days | $1,771.20 |
Browse Plan Formulary |
Fidelis Dual Advantage (HMO D-SNP)
|
$31.80 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:240 /30Days | $1,765.50 |
Browse Plan Formulary |
EmblemHealth VIP Passport NYC (HMO)
|
$32.00 |
$295 |
No |
5 |
Tier 5 |
27% | n/a | P | $1,435.80 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice Plan 3 (Regional PPO)
|
$32.20 |
$275 |
No |
5 |
Tier 5 |
28% | 28% | P Q:90 /30Days | $1,605.30 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H3533-029 (HMO D-SNP)
|
$33.60 |
$390 |
No |
5 |
Tier 5 |
25% | n/a | P Q:240 /30Days | $392.40 |
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 H3533-029 (HMO D-SNP)
|
$33.60 |
$390 |
No |
5 |
Tier 5 |
25% | n/a | P Q:240 /30Days | $392.40 |
Browse Plan Formulary |
Aetna Medicare Elite Plan (HMO)
|
$34.00 |
$300 |
No |
5 |
Tier 5 |
27% | n/a | P Q:90 /30Days | $629.10 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)
|
$34.60 |
$435 |
No |
5 |
Tier 5 |
25% | 25% | P Q:90 /30Days | $1,638.30 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 2 (HMO I-SNP)
|
$34.90 |
$435 |
No |
5 |
Tier 5 |
25% | 25% | P Q:90 /30Days | $1,637.70 |
Browse Plan Formulary |
Elderplan Plus Long Term Care (HMO D-SNP)
|
$35.00 |
$435 |
No |
1 |
Tier 1 |
15% | 15% | P Q:240 /30Days | $1,771.20 |
Browse Plan Formulary |
AgeWell New York Advantage Plus (HMO D-SNP)
|
$36.60 |
$435 |
No |
5 |
Tier 5 |
$0.00 | $0.00 | P | $1,411.50 |
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 CareWell (HMO I-SNP)
|
$36.60 |
$435 |
No |
5 |
Tier 5 |
25% | 25% | P | $1,408.80 |
Browse Plan Formulary |
AgeWell New York FeelWell (HMO D-SNP)
|
$36.60 |
$435 |
No |
5 |
Tier 5 |
$0.00 | $0.00 | P | $1,411.50 |
Browse Plan Formulary |
AgeWell New York LiveWell (HMO)
|
$36.60 |
$290 |
No |
5 |
Tier 5 |
27% | 27% | P | $1,411.50 |
Browse Plan Formulary |
ArchCare Advantage (HMO I-SNP)
|
$36.60 |
$435 |
No |
1 |
Tier 1 |
25% | 25% | P Q:240 /30Days | $1,469.10 |
Browse Plan Formulary |
ArchCare Community Choice (HMO D-SNP)
|
$36.60 |
$435 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:240 /30Days | $1,469.10 |
Browse Plan Formulary |
Bright Advantage Assist (HMO)
|
$36.60 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:240 /30Days | $1,661.40 |
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 |
CenterLight Healthcare Direct Complete Plan (HMO I-SNP)
|
$36.60 |
$435 |
No |
1 |
Tier 1 |
$5.25 | $15.75 | P | $365.40 |
Browse Plan Formulary |
Centers Plan for Dual Coverage Care (HMO D-SNP)
|
$36.60 |
$435 |
No |
1 |
Tier 1 |
15% | 15% | P Q:112 /28Days | $586.80 |
Browse Plan Formulary |
Centers Plan for Nursing Home Care (HMO I-SNP)
|
$36.60 |
$435 |
No |
1 |
Tier 1 |
25% | 25% | P Q:112 /28Days | $597.60 |
Browse Plan Formulary |
Elderplan Advantage For Nursing Home Residents (HMO I-SNP)
|
$36.60 |
$435 |
No |
1 |
Tier 1 |
25% | 25% | P Q:240 /30Days | $1,771.20 |
Browse Plan Formulary |
Elderplan Assist (HMO I-SNP)
|
$36.60 |
$435 |
No |
5 |
Tier 5 |
25% | 25% | P Q:240 /30Days | $1,771.20 |
Browse Plan Formulary |
EmblemHealth VIP Assist (HMO D-SNP)
|
$36.60 |
$435 |
No |
5 |
Tier 5 |
$0.00 | $0.00 | P | $1,459.80 |
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 |
EmblemHealth VIP Connect (HMO D-SNP)
|
$36.60 |
$435 |
No |
5 |
Tier 5 |
$0.00 | $0.00 | P | $1,459.80 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
|
$36.60 |
$435 |
No |
5 |
Tier 5 |
$0.00 | $0.00 | P | $1,411.20 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
|
$36.60 |
$435 |
No |
5 |
Tier 5 |
$0.00 | $0.00 | P | $1,729.80 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
|
$36.60 |
$435 |
No |
5 |
Tier 5 |
$0.00 | $0.00 | P | $1,439.10 |
Browse Plan Formulary |
EmblemHealth VIP Dual Select (HMO D-SNP)
|
$36.60 |
$435 |
No |
5 |
Tier 5 |
$0.00 | $0.00 | P | $1,483.20 |
Browse Plan Formulary |
EmblemHealth VIP Solutions (HMO D-SNP)
|
$36.60 |
$435 |
No |
5 |
Tier 5 |
15% | 15% | P | $1,483.20 |
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 |
Empire MediBlue Dual Advantage (HMO D-SNP)
|
$36.60 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:240 /30Days | $1,771.20 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage Select (HMO D-SNP)
|
$36.60 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:240 /30Days | $1,771.20 |
Browse Plan Formulary |
Hamaspik Medicare Select (HMO D-SNP)
|
$36.60 |
$435 |
No |
1 |
Tier 1 |
15% | 15% | P | $417.00 |
Browse Plan Formulary |
Health Pointe Direct Complete Plan (HMO I-SNP)
|
$36.60 |
$435 |
No |
1 |
Tier 1 |
25% | 25% | P | $365.40 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO D-SNP)
|
$36.60 |
$435 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:240 /30Days | $1,771.20 |
Browse Plan Formulary |
Healthfirst Increased Benefits Plan (HMO)
|
$36.60 |
$435 |
No |
1 |
Tier 1 |
25% | 25% | P Q:240 /30Days | $1,771.20 |
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 |
Healthfirst Life Improvement Plan (HMO D-SNP)
|
$36.60 |
$435 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:240 /30Days | $1,771.20 |
Browse Plan Formulary |
Integra Harmony (HMO D-SNP)
|
$36.60 |
$435 |
No |
1 |
Tier 1 |
15% | 15% | P Q:240 /30Days | $1,651.80 |
Browse Plan Formulary |
Integra Synergy Medicaid Advantage Plus (MAP) (HMO D-SNP)
|
$36.60 |
$435 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:240 /30Days | $1,651.80 |
Browse Plan Formulary |
Longevity Health Plan (HMO I-SNP)
|
$36.60 |
$435 |
No |
1 |
Tier 1 |
25% | n/a | P | $363.90 |
Browse Plan Formulary |
MetroPlus Advantage Plan (HMO D-SNP)
|
$36.60 |
$435 |
No |
1 |
Tier 1 |
15% | 15% | P Q:240 /30Days | $1,632.30 |
Browse Plan Formulary |
RiverSpring MAP (HMO D-SNP)
|
$36.60 |
$435 |
No |
1 |
Tier 1 |
15% | 15% | P Q:240 /30Days | $1,648.20 |
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 |
RiverSpring Star (HMO I-SNP)
|
$36.60 |
$435 |
No |
1 |
Tier 1 |
25% | 25% | P Q:240 /30Days | $1,648.20 |
Browse Plan Formulary |
Senior Whole Health of New York NHC (HMO D-SNP)
|
$36.60 |
$435 |
No |
1 |
Tier 1 |
15% | 15% | P Q:240 /30Days | $1,484.40 |
Browse Plan Formulary |
VillageCareMAX Medicare Health Advantage (HMO D-SNP)
|
$36.60 |
$435 |
No |
1 |
Tier 1 |
15% | 15% | P Q:112 /28Days | $509.70 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO D-SNP)
|
$36.60 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:112 /28Days | $509.70 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice Plan 4 (Regional PPO)
|
$40.60 |
$150 |
No |
5 |
Tier 5 |
30% | 30% | P Q:90 /30Days | $1,605.30 |
Browse Plan Formulary |
Humana Gold Plus H3533-023 (HMO)
|
$48.00 |
$200 |
No |
5 |
Tier 5 |
29% | n/a | P Q:240 /30Days | $392.40 |
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 Medicare Advantage Plan 1 (HMO)
|
$49.00 |
$395 |
No |
5 |
Tier 5 |
25% | 25% | P Q:90 /30Days | $1,642.80 |
Browse Plan Formulary |
Bright Advantage Plus (HMO)
|
$55.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:240 /30Days | $1,661.40 |
Browse Plan Formulary |
EmblemHealth VIP Go (HMO-POS)
|
$71.00 |
$250 |
No |
5 |
Tier 5 |
28% | n/a | P | $1,439.10 |
Browse Plan Formulary |
EmblemHealth VIP Go (HMO-POS)
|
$71.00 |
$250 |
No |
5 |
Tier 5 |
28% | n/a | P | $1,638.30 |
Browse Plan Formulary |
Centers Plan for Medicaid Advantage Plus (HMO D-SNP)
|
$76.00 |
$435 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:112 /28Days | $613.50 |
Browse Plan Formulary |
WellCare Preferred (HMO)
|
$81.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Tier 5 |
33% | n/a | P Q:240 /30Days | $465.30 |
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)
|
$83.00 |
$250 |
No |
5 |
Tier 5 |
28% | n/a | P Q:90 /30Days | $783.60 |
Browse Plan Formulary |
Bright Advantage Flex Plus (PPO)
|
$95.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:240 /30Days | $1,661.40 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$95.00 |
$200 |
No |
5 |
Tier 5 |
29% | n/a | P | $1,868.10 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$95.00 |
$200 |
No |
5 |
Tier 5 |
29% | n/a | P | $1,439.10 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$95.00 |
$200 |
No |
5 |
Tier 5 |
29% | n/a | P | $1,635.60 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$95.00 |
$200 |
No |
5 |
Tier 5 |
29% | n/a | P | $1,455.00 |
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 |
HumanaChoice H5970-022 (PPO)
|
$98.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:240 /30Days | $392.40 |
Browse Plan Formulary |
VillageCareMAX Medicare Total Advantage (HMO D-SNP)
|
$101.00 |
$435 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:112 /28Days | $509.70 |
Browse Plan Formulary |
WellCare Today's Options Advantage Plus 150A (PPO)
|
$136.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:240 /30Days | $484.20 |
Browse Plan Formulary |
MetroPlus Platinum Plan (HMO)
|
$141.00 |
$435 |
No |
1 |
Tier 1 |
25% | 25% | P Q:240 /30Days | $1,632.30 |
Browse Plan Formulary |
HumanaChoice H5970-023 (PPO)
|
$207.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:240 /30Days | $392.40 |
Browse Plan Formulary |
EmblemHealth VIP Gold Plus (HMO)
|
$301.00 |
$200 |
No |
5 |
Tier 5 |
29% | n/a | P | $1,513.20 |
Browse Plan Formulary |