COARTEM 20MG-120MG (24 EA ) (NDC: 00078056845)
2021 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)
![Email Prescription and/or Health Benefit details for Aetna Medicare Elite Plan (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $1,296.00 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Value Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$250 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $1,296.00 |
Browse Plan Formulary |
Centers Plan for Medicare Advantage Care (HMO)
![Email Prescription and/or Health Benefit details for Centers Plan for Medicare Advantage Care (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$395 |
No |
4 |
Non-Preferred Brand |
$100.00 | $250.00 | None | $1,228.80 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Essential (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$295 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,190.40 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Essential (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$295 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,176.00 |
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 |
EmblemHealth VIP Essential (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Essential (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$295 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,183.20 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Essential (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$295 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,185.60 |
Browse Plan Formulary |
EmblemHealth VIP Part B Saver (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Part B Saver (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,188.00 |
Browse Plan Formulary |
EmblemHealth VIP Reserve (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Reserve (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$295 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,185.60 |
Browse Plan Formulary |
Empire MediBlue HealthPlus (HMO)
![Email Prescription and/or Health Benefit details for Empire MediBlue HealthPlus (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$350 |
No |
4 |
Non-Preferred Drug |
$94.00 | $282.00 | None | $1,296.00 |
Browse Plan Formulary |
Empire MediBlue Select (HMO)
![Email Prescription and/or Health Benefit details for Empire MediBlue Select (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$350 |
No |
4 |
Non-Preferred Drug |
$94.00 | $282.00 | None | $1,296.00 |
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 |
Fidelis Medicare $0 Premium (HMO)
![Email Prescription and/or Health Benefit details for Fidelis Medicare $0 Premium (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
50% | 46% | None | $1,296.00 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
![Email Prescription and/or Health Benefit details for Healthfirst 65 Plus Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$350 |
No |
4 |
Non-Preferred Drug |
$100.00 | $100.00 | None | $1,243.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Healthfirst Signature (HMO)
![Email Prescription and/or Health Benefit details for Healthfirst Signature (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$350 |
No |
4 |
Non-Preferred Drug |
$100.00 | $100.00 | None | $1,243.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H3533-027 (HMO)
![Email Prescription and/or Health Benefit details for Humana Gold Plus H3533-027 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$400 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:24 /30Days | $1,288.80 |
Browse Plan Formulary |
HumanaChoice H5970-024 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice H5970-024 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$350 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:24 /30Days | $1,288.80 |
Browse Plan Formulary |
HumanaChoice H5970-024 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice H5970-024 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$350 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:24 /30Days | $1,288.80 |
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 |
Montefiore + Oscar Easy Care (HMO)
![Email Prescription and/or Health Benefit details for Montefiore + Oscar Easy Care (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,291.20 |
Browse Plan Formulary |
PHP Care Complete FIDA-IDD Plan (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for PHP Care Complete FIDA-IDD Plan (Medicare-Medicaid Plan)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | None | $1,190.40 |
Browse Plan Formulary |
WellCare Absolute (PPO)
![Email Prescription and/or Health Benefit details for WellCare Absolute (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $1,296.00 |
Browse Plan Formulary |
WellCare Choice (HMO)
![Email Prescription and/or Health Benefit details for WellCare Choice (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
48% | 48% | None | $1,296.00 |
Browse Plan Formulary |
WellCare Element (HMO)
![Email Prescription and/or Health Benefit details for WellCare Element (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
48% | 48% | None | $1,296.00 |
Browse Plan Formulary |
WellCare Today's Options Advantage Plus 550B (PPO)
![Email Prescription and/or Health Benefit details for WellCare Today's Options Advantage Plus 550B (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $1,293.60 |
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 |
WellCare Summit (PPO)
![Email Prescription and/or Health Benefit details for WellCare Summit (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$5.10 |
$445 |
No |
4 |
Non-Preferred Drug |
50% | 50% | None | $1,296.00 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
![Email Prescription and/or Health Benefit details for Fidelis Medicare Advantage Flex (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$10.90 |
$445 |
No |
4 |
Non-Preferred Drug |
50% | 46% | None | $1,296.00 |
Browse Plan Formulary |
WellCare Compass (HMO)
![Email Prescription and/or Health Benefit details for WellCare Compass (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$12.30 |
$445 |
No |
4 |
Non-Preferred Drug |
50% | 50% | None | $1,296.00 |
Browse Plan Formulary |
WellCare Imperial (PPO D-SNP)
![Email Prescription and/or Health Benefit details for WellCare Imperial (PPO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$12.50 |
$445 |
No |
4 |
Non-Preferred Drug |
49% | 49% | None | $1,296.00 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$16.00 |
$300 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $1,308.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H3533-032 (HMO)
![Email Prescription and/or Health Benefit details for Humana Gold Plus H3533-032 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$21.00 |
$200 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:24 /30Days | $1,269.60 |
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 |
Humana Gold Plus H3533-032 (HMO)
![Email Prescription and/or Health Benefit details for Humana Gold Plus H3533-032 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$21.00 |
$200 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:24 /30Days | $1,288.80 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Fidelis Dual Advantage Flex (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$21.60 |
$445 |
No |
4 |
Non-Preferred Drug |
39% | 35% | None | $1,296.00 |
Browse Plan Formulary |
Fidelis Medicaid Advantage Plus (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Fidelis Medicaid Advantage Plus (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$22.30 |
$445 |
No |
4 |
Non-Preferred Drug |
50% | 46% | None | $1,296.00 |
Browse Plan Formulary |
Fidelis Dual Advantage (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Fidelis Dual Advantage (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$22.50 |
$445 |
No |
4 |
Non-Preferred Drug |
47% | 43% | None | $1,296.00 |
Browse Plan Formulary |
Elderplan Extra Help (HMO)
![Email Prescription and/or Health Benefit details for Elderplan Extra Help (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$25.30 |
$445 |
No |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $1,192.80 |
Browse Plan Formulary |
Aetna Medicare Assure Plan (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Aetna Medicare Assure Plan (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$25.70 |
$190 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $1,296.00 |
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 |
WellCare Access (HMO D-SNP)
![Email Prescription and/or Health Benefit details for WellCare Access (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$27.10 |
$445 |
No |
4 |
Non-Preferred Drug |
45% | 45% | None | $1,296.00 |
Browse Plan Formulary |
Elderplan Plus Long Term Care (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Elderplan Plus Long Term Care (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$31.80 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | None | $1,192.80 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$32.60 |
$445 |
No |
4 |
Tier 4 |
25% | 25% | None | $1,310.40 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 2 (HMO)
![Email Prescription and/or Health Benefit details for AARP Medicare Advantage Plan 2 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$34.00 |
$395 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $1,310.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Elderplan For Medicaid Beneficiaries (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Elderplan For Medicaid Beneficiaries (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$35.40 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | None | $1,192.80 |
Browse Plan Formulary |
Elderplan Advantage For Nursing Home Residents (HMO I-SNP)
![Email Prescription and/or Health Benefit details for Elderplan Advantage For Nursing Home Residents (HMO I-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$35.50 |
$445 |
No |
1 |
Tier 1 |
25% | 25% | None | $1,192.80 |
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 Medicare Advantage Choice Plan 3 (Regional PPO)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Medicare Advantage Choice Plan 3 (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$35.60 |
$275 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $1,308.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Nursing Home Plan 2 (HMO I-SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Nursing Home Plan 2 (HMO I-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$35.90 |
$445 |
No |
4 |
Tier 4 |
25% | 25% | None | $1,310.40 |
Browse Plan Formulary |
Aetna Medicare Elite Plan 2 (PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Elite Plan 2 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$39.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $1,315.20 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H3533-031 (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Humana Gold Plus SNP-DE H3533-031 (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$40.30 |
$435 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:24 /30Days | $1,288.80 |
Browse Plan Formulary |
AgeWell New York Advantage Plus (HMO D-SNP)
![Email Prescription and/or Health Benefit details for AgeWell New York Advantage Plus (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
4 |
Tier 4 |
$0.00 | $0.00 | None | $1,238.40 |
Browse Plan Formulary |
AgeWell New York CareWell (HMO I-SNP)
![Email Prescription and/or Health Benefit details for AgeWell New York CareWell (HMO I-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
4 |
Tier 4 |
25% | 25% | None | $1,236.00 |
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 |
AgeWell New York FeelWell (HMO D-SNP)
![Email Prescription and/or Health Benefit details for AgeWell New York FeelWell (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
4 |
Tier 4 |
$0.00 | $0.00 | None | $1,238.40 |
Browse Plan Formulary |
AgeWell New York LiveWell (HMO)
![Email Prescription and/or Health Benefit details for AgeWell New York LiveWell (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$350 |
No |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | None | $1,238.40 |
Browse Plan Formulary |
ArchCare Advantage (HMO I-SNP)
![Email Prescription and/or Health Benefit details for ArchCare Advantage (HMO I-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
1 |
Tier 1 |
25% | 25% | None | $1,207.20 |
Browse Plan Formulary |
Centers Plan for Dual Coverage Care (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Centers Plan for Dual Coverage Care (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | None | $1,228.80 |
Browse Plan Formulary |
Centers Plan for Nursing Home Care (HMO I-SNP)
![Email Prescription and/or Health Benefit details for Centers Plan for Nursing Home Care (HMO I-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
1 |
Tier 1 |
25% | 25% | None | $1,228.80 |
Browse Plan Formulary |
Elderplan Assist (HMO I-SNP)
![Email Prescription and/or Health Benefit details for Elderplan Assist (HMO I-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | None | $1,192.80 |
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 Assist (HMO D-SNP)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Assist (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
4 |
Tier 4 |
$0.00 | $0.00 | None | $1,178.40 |
Browse Plan Formulary |
EmblemHealth VIP Connect (HMO D-SNP)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Connect (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
4 |
Tier 4 |
$0.00 | $0.00 | None | $1,178.40 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Dual (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
4 |
Tier 4 |
$0.00 | $0.00 | None | $1,185.60 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Dual (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
4 |
Tier 4 |
$0.00 | $0.00 | None | $1,192.80 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Dual (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
4 |
Tier 4 |
$0.00 | $0.00 | None | $1,176.00 |
Browse Plan Formulary |
EmblemHealth VIP Dual Reserve (HMO D-SNP)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Dual Reserve (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
4 |
Tier 4 |
$0.00 | $0.00 | None | $1,185.60 |
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 Dual Select (HMO D-SNP)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Dual Select (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
4 |
Tier 4 |
$0.00 | $0.00 | None | $1,183.20 |
Browse Plan Formulary |
EmblemHealth VIP Passport NYC (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Passport NYC (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$295 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,185.60 |
Browse Plan Formulary |
EmblemHealth VIP Solutions (HMO D-SNP)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Solutions (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
4 |
Tier 4 |
15% | 15% | None | $1,185.60 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Empire MediBlue Dual Advantage (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,293.60 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage Select (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Empire MediBlue Dual Advantage Select (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,293.60 |
Browse Plan Formulary |
Empire MediBlue Extra Select (HMO)
![Email Prescription and/or Health Benefit details for Empire MediBlue Extra Select (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,296.00 |
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 |
Empire MediBlue HealthPlus Dual Advantage (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Empire MediBlue HealthPlus Dual Advantage (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,293.60 |
Browse Plan Formulary |
Empire MediBlue HealthPlus Dual Connect (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Empire MediBlue HealthPlus Dual Connect (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,293.60 |
Browse Plan Formulary |
Empire MediBlue HealthPlus Dual Plus (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Empire MediBlue HealthPlus Dual Plus (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,293.60 |
Browse Plan Formulary |
Hamaspik Medicare Choice (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Hamaspik Medicare Choice (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | None | $1,200.00 |
Browse Plan Formulary |
Hamaspik Medicare Select (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Hamaspik Medicare Select (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | None | $1,200.00 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Healthfirst CompleteCare (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | None | $1,243.20 |
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 Increased Benefits Plan (HMO)
![Email Prescription and/or Health Benefit details for Healthfirst Increased Benefits Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
1 |
Tier 1 |
25% | 25% | None | $1,243.20 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Healthfirst Life Improvement Plan (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | None | $1,243.20 |
Browse Plan Formulary |
Integra Balanced Medicaid Advantage (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Integra Balanced Medicaid Advantage (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | None | $1,238.40 |
Browse Plan Formulary |
Integra Harmony (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Integra Harmony (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | None | $1,238.40 |
Browse Plan Formulary |
Integra Synergy Medicaid Advantage Plus (MAP) (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Integra Synergy Medicaid Advantage Plus (MAP) (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | None | $1,238.40 |
Browse Plan Formulary |
Longevity Health Plan (HMO I-SNP)
![Email Prescription and/or Health Benefit details for Longevity Health Plan (HMO I-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
1 |
Tier 1 |
25% | n/a | None | $1,219.20 |
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 |
MetroPlus Advantage Plan (HMO D-SNP)
![Email Prescription and/or Health Benefit details for MetroPlus Advantage Plan (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | None | $1,192.80 |
Browse Plan Formulary |
MetroPlus UltraCare (HMO D-SNP)
![Email Prescription and/or Health Benefit details for MetroPlus UltraCare (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | None | $1,192.80 |
Browse Plan Formulary |
Montefiore + Oscar Extra Benefits (HMO)
![Email Prescription and/or Health Benefit details for Montefiore + Oscar Extra Benefits (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
1 |
Tier 1 |
25% | 25% | None | $1,291.20 |
Browse Plan Formulary |
RiverSpring MAP (HMO D-SNP)
![Email Prescription and/or Health Benefit details for RiverSpring MAP (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | None | $1,212.00 |
Browse Plan Formulary |
RiverSpring Star (HMO I-SNP)
![Email Prescription and/or Health Benefit details for RiverSpring Star (HMO I-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
1 |
Tier 1 |
25% | 25% | None | $1,212.00 |
Browse Plan Formulary |
Senior Whole Health of New York NHC (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Senior Whole Health of New York NHC (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | None | $1,183.20 |
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 |
UnitedHealthcare Dual Complete (HMO D-SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Dual Complete (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
4 |
Tier 4 |
$0.00 | $0.00 | None | $1,308.00 |
Browse Plan Formulary |
VillageCareMAX Medicare Health Advantage (HMO D-SNP)
![Email Prescription and/or Health Benefit details for VillageCareMAX Medicare Health Advantage (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | None | $1,190.40 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO D-SNP)
![Email Prescription and/or Health Benefit details for VNSNY CHOICE Total (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.30 |
$445 |
No |
4 |
Non-Preferred Brand |
39% | 39% | None | $1,219.20 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice Plan 4 (Regional PPO)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Medicare Advantage Choice Plan 4 (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$43.70 |
$150 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $1,308.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
EmblemHealth VIP Rx Saver (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Rx Saver (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$49.00 |
$395 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,214.40 |
Browse Plan Formulary |
EmblemHealth VIP Rx Saver (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Rx Saver (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$49.00 |
$395 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,190.40 |
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)
![Email Prescription and/or Health Benefit details for AARP Medicare Advantage Plan 1 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$54.00 |
$395 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $1,310.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
EmblemHealth VIP Go (HMO-POS)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Go (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$72.00 |
$250 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,176.00 |
Browse Plan Formulary |
EmblemHealth VIP Go (HMO-POS)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Go (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$72.00 |
$250 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,192.80 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Premier Plan (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$76.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $1,315.20 |
Browse Plan Formulary |
WellCare Preferred (HMO)
![Email Prescription and/or Health Benefit details for WellCare Preferred (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$81.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | None | $1,296.00 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Gold (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$96.00 |
$200 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,190.40 |
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 |
EmblemHealth VIP Gold (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Gold (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$96.00 |
$200 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,176.00 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Gold (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$96.00 |
$200 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,183.20 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Gold (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$96.00 |
$200 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,185.60 |
Browse Plan Formulary |
Centers Plan for Medicaid Advantage (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Centers Plan for Medicaid Advantage (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$101.00 |
$445 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | None | $1,228.80 |
Browse Plan Formulary |
Centers Plan for Medicaid Advantage Plus (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Centers Plan for Medicaid Advantage Plus (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$101.00 |
$445 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | None | $1,228.80 |
Browse Plan Formulary |
VillageCareMAX Medicare Total Advantage (HMO D-SNP)
![Email Prescription and/or Health Benefit details for VillageCareMAX Medicare Total Advantage (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$116.00 |
$445 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | None | $1,190.40 |
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 |
MetroPlus Platinum Plan (HMO)
![Email Prescription and/or Health Benefit details for MetroPlus Platinum Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$148.50 |
$445 |
No |
1 |
Tier 1 |
25% | 25% | None | $1,192.80 |
Browse Plan Formulary |
EmblemHealth VIP Gold Plus (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Gold Plus (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$302.00 |
$200 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,183.20 |
Browse Plan Formulary |