OZEMPIC 0.25-0.5 MG DOSE PEN (1.5 ) (NDC: 00169413212)
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)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $1,198.90 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$250 |
No |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $1,199.06 |
Browse Plan Formulary |
Centers Plan for Medicare Advantage Care (HMO)
|
$0.00 |
$395 |
No |
3 |
Preferred Brand |
$47.00 | $117.50 | Q:3 /28Days | $1,147.80 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$295 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:2 /28Days | $1,106.34 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$295 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:2 /28Days | $1,110.92 |
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)
|
$0.00 |
$295 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:2 /28Days | $1,113.50 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$295 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:2 /28Days | $1,100.10 |
Browse Plan Formulary |
EmblemHealth VIP Part B Saver (HMO)
|
$0.00 |
$445 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:2 /28Days | $1,104.80 |
Browse Plan Formulary |
EmblemHealth VIP Reserve (HMO)
|
$0.00 |
$295 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:2 /28Days | $1,100.10 |
Browse Plan Formulary |
Empire MediBlue HealthPlus (HMO)
|
$0.00 |
$350 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,193.38 |
Browse Plan Formulary |
Empire MediBlue Select (HMO)
|
$0.00 |
$350 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,193.38 |
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)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:2 /28Days | $1,199.72 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$350 |
No |
3 |
Preferred Brand |
$47.00 | $47.00 | Q:2 /28Days | $1,150.68 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Healthfirst Signature (HMO)
|
$0.00 |
$350 |
No |
3 |
Preferred Brand |
$47.00 | $47.00 | Q:2 /28Days | $1,150.68 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H3533-027 (HMO)
|
$0.00 |
$400 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,197.20 |
Browse Plan Formulary |
HumanaChoice H5970-024 (PPO)
|
$0.00 |
$350* |
No |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,203.20 |
Browse Plan Formulary |
HumanaChoice H5970-024 (PPO)
|
$0.00 |
$350* |
No |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,194.92 |
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)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:2 /28Days | $1,104.60 |
Browse Plan Formulary |
PHP Care Complete FIDA-IDD Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | Q:3 /28Days | $1,102.32 |
Browse Plan Formulary |
WellCare Absolute (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:2 /28Days | $1,199.70 |
Browse Plan Formulary |
WellCare Choice (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:2 /28Days | $1,199.70 |
Browse Plan Formulary |
WellCare Element (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:2 /28Days | $1,199.74 |
Browse Plan Formulary |
WellCare Today's Options Advantage Plus 550B (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $74.00 | Q:2 /28Days | $1,193.88 |
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 |
WellCare Summit (PPO)
|
$5.10 |
$445 |
No |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:2 /28Days | $1,199.70 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
|
$10.90 |
$445 |
No |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:2 /28Days | $1,199.72 |
Browse Plan Formulary |
WellCare Compass (HMO)
|
$12.30 |
$445 |
No |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:2 /28Days | $1,199.74 |
Browse Plan Formulary |
WellCare Imperial (PPO D-SNP)
|
$12.50 |
$445 |
No |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:2 /28Days | $1,199.70 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$16.00 |
$350 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,195.34 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$16.00 |
$350 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,191.80 |
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 |
Empire MediBlue Plus (HMO)
|
$16.00 |
$350 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $1,195.66 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO)
|
$16.00 |
$300 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,211.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H3533-032 (HMO)
|
$21.00 |
$200 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,203.58 |
Browse Plan Formulary |
Humana Gold Plus H3533-032 (HMO)
|
$21.00 |
$200 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,194.92 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO D-SNP)
|
$21.60 |
$445 |
No |
3 |
Preferred Brand |
24% | 20% | Q:2 /28Days | $1,199.68 |
Browse Plan Formulary |
Fidelis Medicaid Advantage Plus (HMO D-SNP)
|
$22.30 |
$445 |
No |
3 |
Preferred Brand |
$40.00 | $80.00 | Q:2 /28Days | $1,199.66 |
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 D-SNP)
|
$22.50 |
$445 |
No |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:2 /28Days | $1,199.68 |
Browse Plan Formulary |
Elderplan Extra Help (HMO)
|
$25.30 |
$445* |
No |
3* |
Preferred Brand |
$47.00 | $94.00 | Q:2 /28Days | $1,104.58 |
Browse Plan Formulary |
Aetna Medicare Assure Plan (HMO D-SNP)
|
$25.70 |
$190 |
No |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $1,198.90 |
Browse Plan Formulary |
WellCare Access (HMO D-SNP)
|
$27.10 |
$445 |
No |
3 |
Preferred Brand |
$40.00 | $80.00 | Q:2 /28Days | $1,199.70 |
Browse Plan Formulary |
Elderplan Plus Long Term Care (HMO D-SNP)
|
$31.80 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | Q:2 /28Days | $1,104.56 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)
|
$32.60 |
$445 |
No |
3 |
Tier 3 |
25% | 25% | Q:2 /28Days | $1,211.86 |
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 2 (HMO)
|
$34.00 |
$395 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,211.96 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Elderplan For Medicaid Beneficiaries (HMO D-SNP)
|
$35.40 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | Q:2 /28Days | $1,104.58 |
Browse Plan Formulary |
Elderplan Advantage For Nursing Home Residents (HMO I-SNP)
|
$35.50 |
$445 |
No |
1 |
Tier 1 |
25% | 25% | Q:2 /28Days | $1,104.56 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice Plan 3 (Regional PPO)
|
$35.60 |
$275 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,211.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Nursing Home Plan 2 (HMO I-SNP)
|
$35.90 |
$445 |
No |
3 |
Tier 3 |
25% | 25% | Q:2 /28Days | $1,211.88 |
Browse Plan Formulary |
Aetna Medicare Elite Plan 2 (PPO)
|
$39.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $1,199.06 |
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 H3533-031 (HMO D-SNP)
|
$40.30 |
$435 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,197.20 |
Browse Plan Formulary |
AgeWell New York Advantage Plus (HMO D-SNP)
|
$42.30 |
$445 |
No |
3 |
Tier 3 |
$0.00 | $0.00 | None | $1,148.86 |
Browse Plan Formulary |
AgeWell New York CareWell (HMO I-SNP)
|
$42.30 |
$445 |
No |
3 |
Tier 3 |
25% | 25% | None | $1,149.48 |
Browse Plan Formulary |
AgeWell New York FeelWell (HMO D-SNP)
|
$42.30 |
$445 |
No |
3 |
Tier 3 |
$0.00 | $0.00 | None | $1,148.86 |
Browse Plan Formulary |
AgeWell New York LiveWell (HMO)
|
$42.30 |
$350 |
No |
3 |
Preferred Brand |
$47.00 | $117.50 | None | $1,148.86 |
Browse Plan Formulary |
ArchCare Advantage (HMO I-SNP)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
25% | 25% | Q:2 /28Days | $1,115.06 |
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 |
Centers Plan for Dual Coverage Care (HMO D-SNP)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | Q:3 /28Days | $1,146.02 |
Browse Plan Formulary |
Centers Plan for Nursing Home Care (HMO I-SNP)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
25% | 25% | Q:3 /28Days | $1,147.68 |
Browse Plan Formulary |
Elderplan Assist (HMO I-SNP)
|
$42.30 |
$445* |
No |
3* |
Preferred Brand |
$47.00 | $94.00 | Q:2 /28Days | $1,104.56 |
Browse Plan Formulary |
EmblemHealth VIP Assist (HMO D-SNP)
|
$42.30 |
$445 |
No |
3 |
Tier 3 |
$0.00 | $0.00 | Q:2 /28Days | $1,102.06 |
Browse Plan Formulary |
EmblemHealth VIP Connect (HMO D-SNP)
|
$42.30 |
$445 |
No |
3 |
Tier 3 |
$0.00 | $0.00 | Q:2 /28Days | $1,102.06 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
|
$42.30 |
$445 |
No |
3 |
Tier 3 |
$0.00 | $0.00 | Q:2 /28Days | $1,098.74 |
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 D-SNP)
|
$42.30 |
$445 |
No |
3 |
Tier 3 |
$0.00 | $0.00 | Q:2 /28Days | $1,108.20 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
|
$42.30 |
$445 |
No |
3 |
Tier 3 |
$0.00 | $0.00 | Q:2 /28Days | $1,108.88 |
Browse Plan Formulary |
EmblemHealth VIP Dual Reserve (HMO D-SNP)
|
$42.30 |
$445 |
No |
3 |
Tier 3 |
$0.00 | $0.00 | Q:2 /28Days | $1,098.74 |
Browse Plan Formulary |
EmblemHealth VIP Dual Select (HMO D-SNP)
|
$42.30 |
$445 |
No |
3 |
Tier 3 |
$0.00 | $0.00 | Q:2 /28Days | $1,102.44 |
Browse Plan Formulary |
EmblemHealth VIP Passport NYC (HMO)
|
$42.30 |
$295 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:2 /28Days | $1,100.66 |
Browse Plan Formulary |
EmblemHealth VIP Solutions (HMO D-SNP)
|
$42.30 |
$445 |
No |
3 |
Tier 3 |
15% | 15% | Q:2 /28Days | $1,103.28 |
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 |
Empire MediBlue Dual Advantage (HMO D-SNP)
|
$42.30 |
$445 |
No |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $1,190.96 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage Select (HMO D-SNP)
|
$42.30 |
$445 |
No |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $1,190.74 |
Browse Plan Formulary |
Empire MediBlue Extra Select (HMO)
|
$42.30 |
$445 |
No |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $1,193.38 |
Browse Plan Formulary |
Empire MediBlue HealthPlus Dual Advantage (HMO D-SNP)
|
$42.30 |
$445 |
No |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $1,189.56 |
Browse Plan Formulary |
Empire MediBlue HealthPlus Dual Connect (HMO D-SNP)
|
$42.30 |
$445 |
No |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $1,189.56 |
Browse Plan Formulary |
Empire MediBlue HealthPlus Dual Plus (HMO D-SNP)
|
$42.30 |
$445 |
No |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $1,189.56 |
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 |
Hamaspik Medicare Choice (HMO D-SNP)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | Q:2 /28Days | $1,111.90 |
Browse Plan Formulary |
Hamaspik Medicare Select (HMO D-SNP)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | Q:2 /28Days | $1,112.00 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO D-SNP)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | Q:2 /28Days | $1,150.68 |
Browse Plan Formulary |
Healthfirst Increased Benefits Plan (HMO)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
25% | 25% | Q:2 /28Days | $1,150.68 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO D-SNP)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | Q:2 /28Days | $1,150.68 |
Browse Plan Formulary |
Integra Balanced Medicaid Advantage (HMO D-SNP)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | None | $1,147.98 |
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 Harmony (HMO D-SNP)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | None | $1,147.98 |
Browse Plan Formulary |
Integra Synergy Medicaid Advantage Plus (MAP) (HMO D-SNP)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | None | $1,147.98 |
Browse Plan Formulary |
Longevity Health Plan (HMO I-SNP)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
25% | n/a | Q:2 /28Days | $1,130.56 |
Browse Plan Formulary |
MetroPlus Advantage Plan (HMO D-SNP)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | Q:2 /28Days | $1,104.00 |
Browse Plan Formulary |
MetroPlus UltraCare (HMO D-SNP)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | Q:2 /28Days | $1,104.00 |
Browse Plan Formulary |
Montefiore + Oscar Extra Benefits (HMO)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
25% | 25% | Q:2 /28Days | $1,104.60 |
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 |
RiverSpring MAP (HMO D-SNP)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | Q:2 /28Days | $1,123.06 |
Browse Plan Formulary |
RiverSpring Star (HMO I-SNP)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
25% | 25% | Q:2 /28Days | $1,123.06 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$42.30 |
$445 |
No |
3 |
Tier 3 |
$0.00 | $0.00 | Q:2 /28Days | $1,211.62 |
Browse Plan Formulary |
VillageCareMAX Medicare Health Advantage (HMO D-SNP)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | Q:3 /28Days | $1,102.30 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO D-SNP)
|
$42.30 |
$445 |
No |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:3 /28Days | $1,133.04 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice Plan 4 (Regional PPO)
|
$43.70 |
$150 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,211.64 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
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 Rx Saver (HMO)
|
$49.00 |
$395* |
No |
3* |
Preferred Brand |
$42.00 | $126.00 | Q:2 /28Days | $1,110.82 |
Browse Plan Formulary |
EmblemHealth VIP Rx Saver (HMO)
|
$49.00 |
$395* |
No |
3* |
Preferred Brand |
$42.00 | $126.00 | Q:2 /28Days | $1,102.58 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 1 (HMO)
|
$54.00 |
$395 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $1,211.96 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
EmblemHealth VIP Go (HMO-POS)
|
$72.00 |
$250 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:2 /28Days | $1,110.92 |
Browse Plan Formulary |
EmblemHealth VIP Go (HMO-POS)
|
$72.00 |
$250 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:2 /28Days | $1,104.16 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$76.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $1,199.06 |
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 Preferred (HMO)
|
$81.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:2 /28Days | $1,199.76 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$96.00 |
$200 |
No |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:2 /28Days | $1,106.34 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$96.00 |
$200 |
No |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:2 /28Days | $1,110.92 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$96.00 |
$200 |
No |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:2 /28Days | $1,113.50 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$96.00 |
$200 |
No |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:2 /28Days | $1,100.10 |
Browse Plan Formulary |
Centers Plan for Medicaid Advantage (HMO D-SNP)
|
$101.00 |
$445 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | Q:3 /28Days | $1,146.02 |
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 |
Centers Plan for Medicaid Advantage Plus (HMO D-SNP)
|
$101.00 |
$445 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | Q:3 /28Days | $1,146.54 |
Browse Plan Formulary |
VillageCareMAX Medicare Total Advantage (HMO D-SNP)
|
$116.00 |
$445 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | Q:3 /28Days | $1,102.30 |
Browse Plan Formulary |
MetroPlus Platinum Plan (HMO)
|
$148.50 |
$445 |
No |
1 |
Tier 1 |
25% | 25% | Q:2 /28Days | $1,104.00 |
Browse Plan Formulary |
EmblemHealth VIP Gold Plus (HMO)
|
$302.00 |
$200 |
No |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:2 /28Days | $1,103.92 |
Browse Plan Formulary |