VICTOZA 3-PAK 18 MG/3 ML PEN (9ML ) (NDC: 00169406013)
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 |
AARP Medicare Advantage Mosaic Choice (PPO)
|
$0.00 |
$250 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:9 /30Days | $1,084.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Prime (HMO)
|
$0.00 |
$295 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:9 /30Days | $1,084.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Elite Plan (PPO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:9 /30Days | $1,072.98 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$250 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:9 /30Days | $1,073.16 |
Browse Plan Formulary |
Bright Advantage (HMO)
|
$0.00 |
$445 | No | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:9 /28Days | $1,028.07 |
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 Choice (PPO)
|
$0.00 |
$445 | No | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:9 /28Days | $1,028.07 |
Browse Plan Formulary |
Bright Advantage Senior Savings (HMO C-SNP)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:9 /28Days | $1,028.07 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Centers Plan for Medicare Advantage Care (HMO)
|
$0.00 |
$395 | No | 3 |
Preferred Brand |
$47.00 | $117.50 | Q:9 /30Days | $1,027.08 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$295 | No | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:9 /30Days | $984.69 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$295 | No | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:9 /30Days | $997.29 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$295 | No | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:9 /30Days | $993.60 |
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 Essential (HMO)
|
$0.00 |
$295 | No | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:9 /30Days | $992.52 |
Browse Plan Formulary |
EmblemHealth VIP Part B Saver (HMO)
|
$0.00 |
$445 | No | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:9 /30Days | $990.09 |
Browse Plan Formulary |
EmblemHealth VIP Reserve (HMO)
|
$0.00 |
$295 | No | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:9 /30Days | $984.69 |
Browse Plan Formulary |
Empire MediBlue HealthPlus (HMO)
|
$0.00 |
$350 | No | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:9 /30Days | $1,068.03 |
Browse Plan Formulary |
Empire MediBlue Select (HMO)
|
$0.00 |
$350 | No | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:9 /30Days | $1,068.03 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$350 | No | 3 |
Preferred Brand |
$47.00 | $47.00 | Q:9 /30Days | $1,029.87 |
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 |
Healthfirst Signature (HMO)
|
$0.00 |
$350 | No | 3 |
Preferred Brand |
$47.00 | $47.00 | Q:9 /30Days | $1,029.87 |
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:9 /30Days | $1,071.81 |
Browse Plan Formulary |
Humana Gold Plus H3533-033 (HMO)
|
$0.00 |
$350 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:9 /30Days | $1,070.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5970-024 (PPO)
|
$0.00 |
$350* | No | 3* |
Preferred Brand |
$47.00 | $131.00 | Q:9 /30Days | $1,069.65 |
Browse Plan Formulary |
HumanaChoice H5970-024 (PPO)
|
$0.00 |
$350* | No | 3* |
Preferred Brand |
$47.00 | $131.00 | Q:9 /30Days | $1,076.94 |
Browse Plan Formulary |
PHP Care Complete FIDA-IDD Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
0% | 0% | Q:9 /30Days | $986.58 |
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 Absolute (PPO)
|
$0.00 |
$150 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:9 /30Days | $1,073.61 |
Browse Plan Formulary |
WellCare Choice (HMO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:9 /30Days | $1,073.70 |
Browse Plan Formulary |
WellCare Element (HMO)
|
$0.00 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:9 /30Days | $1,073.70 |
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:9 /30Days | $1,068.12 |
Browse Plan Formulary |
WellCare Summit (PPO)
|
$5.10 |
$445 | No | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:9 /30Days | $1,073.61 |
Browse Plan Formulary |
WellCare Compass (HMO)
|
$12.30 |
$445 | No | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:9 /30Days | $1,073.70 |
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 Imperial (PPO D-SNP)
|
$12.50 |
$445 | No | 3 |
Preferred Brand |
$45.00 | $90.00 | Q:9 /30Days | $1,073.61 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$16.00 |
$350 | No | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:9 /30Days | $1,070.73 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$16.00 |
$350 | No | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:9 /30Days | $1,065.96 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$16.00 |
$350 | No | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:9 /30Days | $1,070.01 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO)
|
$16.00 |
$300 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:9 /30Days | $1,084.14 |
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:9 /30Days | $1,069.65 |
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)
|
$21.00 |
$200 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:9 /30Days | $1,078.20 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO D-SNP)
|
$21.60 |
$445 | No | 3 |
Preferred Brand |
24% | 20% | Q:9 /30Days | $1,073.61 |
Browse Plan Formulary |
Aetna Medicare Value Plan (PPO)
|
$22.00 |
$250 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:9 /30Days | $1,073.16 |
Browse Plan Formulary |
Fidelis Medicaid Advantage Plus (HMO D-SNP)
|
$22.30 |
$445 | No | 3 |
Preferred Brand |
$40.00 | $80.00 | Q:9 /30Days | $1,073.61 |
Browse Plan Formulary |
Fidelis Dual Advantage (HMO D-SNP)
|
$22.50 |
$445 | No | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:9 /30Days | $1,073.61 |
Browse Plan Formulary |
Elderplan Extra Help (HMO)
|
$25.30 |
$445* | No | 3* |
Preferred Brand |
$47.00 | $94.00 | Q:9 /30Days | $988.56 |
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 |
Aetna Medicare Assure Plan (HMO D-SNP)
|
$25.70 |
$190 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:9 /30Days | $1,072.98 |
Browse Plan Formulary |
WellCare Access (HMO D-SNP)
|
$27.10 |
$445 | No | 3 |
Preferred Brand |
$40.00 | $80.00 | Q:9 /30Days | $1,073.70 |
Browse Plan Formulary |
Elderplan Plus Long Term Care (HMO D-SNP)
|
$31.80 |
$445 | No | 1 |
Tier 1 |
15% | 15% | Q:9 /30Days | $988.56 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)
|
$32.60 |
$445 | No | 3 |
Tier 3 |
25% | 25% | Q:9 /30Days | $1,084.32 |
Browse Plan Formulary |
Bright Advantage Senior Savings Assist (HMO C-SNP)
|
$33.90 |
$0 | No | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:9 /28Days | $1,028.07 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
AARP Medicare Advantage Plan 2 (HMO)
|
$34.00 |
$395 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:9 /30Days | $1,084.59 |
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 |
Elderplan For Medicaid Beneficiaries (HMO D-SNP)
|
$35.40 |
$445 | No | 1 |
Tier 1 |
15% | 15% | Q:9 /30Days | $988.56 |
Browse Plan Formulary |
Elderplan Advantage For Nursing Home Residents (HMO I-SNP)
|
$35.50 |
$445 | No | 1 |
Tier 1 |
25% | 25% | Q:9 /30Days | $988.56 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice Plan 3 (Regional PPO)
|
$35.60 |
$275 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:9 /30Days | $1,084.14 |
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:9 /30Days | $1,084.32 |
Browse Plan Formulary |
Aetna Medicare Elite Plan 3 (PPO)
|
$39.00 |
$300 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:9 /30Days | $1,073.16 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H3533-031 (HMO D-SNP)
|
$40.30 |
$435 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:9 /30Days | $1,071.81 |
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 D-SNP)
|
$42.30 |
$445 | No | 3 |
Tier 3 |
$0.00 | $0.00 | None | $1,028.70 |
Browse Plan Formulary |
AgeWell New York CareWell (HMO I-SNP)
|
$42.30 |
$445 | No | 3 |
Tier 3 |
25% | 25% | None | $1,029.15 |
Browse Plan Formulary |
AgeWell New York FeelWell (HMO D-SNP)
|
$42.30 |
$445 | No | 3 |
Tier 3 |
$0.00 | $0.00 | None | $1,028.70 |
Browse Plan Formulary |
AgeWell New York LiveWell (HMO)
|
$42.30 |
$350 | No | 3 |
Preferred Brand |
$47.00 | $117.50 | None | $1,028.70 |
Browse Plan Formulary |
ArchCare Advantage (HMO I-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
25% | 25% | Q:9 /30Days | $997.92 |
Browse Plan Formulary |
Bright Advantage Assist (HMO)
|
$42.30 |
$445 | No | 3 |
Preferred Brand |
25% | 25% | Q:9 /28Days | $1,028.07 |
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 Special Care (HMO D-SNP)
|
$42.30 |
$445 | No | 3 |
Tier 3 |
$0.00 | $0.00 | Q:9 /28Days | $1,028.07 |
Browse Plan Formulary |
Centers Plan for Dual Coverage Care (HMO D-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
15% | 15% | Q:9 /30Days | $1,025.55 |
Browse Plan Formulary |
Centers Plan for Nursing Home Care (HMO I-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
25% | 25% | Q:9 /30Days | $1,026.99 |
Browse Plan Formulary |
Elderplan Assist (HMO I-SNP)
|
$42.30 |
$445* | No | 3* |
Preferred Brand |
$47.00 | $94.00 | Q:9 /30Days | $988.56 |
Browse Plan Formulary |
EmblemHealth VIP Assist (HMO D-SNP)
|
$42.30 |
$445 | No | 3 |
Tier 3 |
$0.00 | $0.00 | Q:9 /30Days | $986.76 |
Browse Plan Formulary |
EmblemHealth VIP Connect (HMO D-SNP)
|
$42.30 |
$445 | No | 3 |
Tier 3 |
$0.00 | $0.00 | Q:9 /30Days | $986.76 |
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 |
EmblemHealth VIP Dual (HMO D-SNP)
|
$42.30 |
$445 | No | 3 |
Tier 3 |
$0.00 | $0.00 | Q:9 /30Days | $983.43 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
|
$42.30 |
$445 | No | 3 |
Tier 3 |
$0.00 | $0.00 | Q:9 /30Days | $992.07 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
|
$42.30 |
$445 | No | 3 |
Tier 3 |
$0.00 | $0.00 | Q:9 /30Days | $993.42 |
Browse Plan Formulary |
EmblemHealth VIP Dual Reserve (HMO D-SNP)
|
$42.30 |
$445 | No | 3 |
Tier 3 |
$0.00 | $0.00 | Q:9 /30Days | $983.43 |
Browse Plan Formulary |
EmblemHealth VIP Dual Select (HMO D-SNP)
|
$42.30 |
$445 | No | 3 |
Tier 3 |
$0.00 | $0.00 | Q:9 /30Days | $987.48 |
Browse Plan Formulary |
EmblemHealth VIP Passport NYC (HMO)
|
$42.30 |
$295 | No | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:9 /30Days | $985.14 |
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 Solutions (HMO D-SNP)
|
$42.30 |
$445 | No | 3 |
Tier 3 |
15% | 15% | Q:9 /30Days | $988.65 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage (HMO D-SNP)
|
$42.30 |
$445 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:9 /30Days | $1,065.15 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage Select (HMO D-SNP)
|
$42.30 |
$445 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:9 /30Days | $1,064.88 |
Browse Plan Formulary |
Empire MediBlue Extra Select (HMO)
|
$42.30 |
$445 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:9 /30Days | $1,068.03 |
Browse Plan Formulary |
Empire MediBlue HealthPlus Dual Advantage (HMO D-SNP)
|
$42.30 |
$445 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:9 /30Days | $1,063.89 |
Browse Plan Formulary |
Empire MediBlue HealthPlus Dual Connect (HMO D-SNP)
|
$42.30 |
$445 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:9 /30Days | $1,063.89 |
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 |
Empire MediBlue HealthPlus Dual Plus (HMO D-SNP)
|
$42.30 |
$445 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:9 /30Days | $1,063.89 |
Browse Plan Formulary |
Hamaspik Medicare Choice (HMO D-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
15% | 15% | Q:9 /30Days | $995.40 |
Browse Plan Formulary |
Hamaspik Medicare Select (HMO D-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
15% | 15% | Q:9 /30Days | $995.49 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO D-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
$0.00 | $0.00 | Q:9 /30Days | $1,029.87 |
Browse Plan Formulary |
Healthfirst Increased Benefits Plan (HMO)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
25% | 25% | Q:9 /30Days | $1,029.87 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO D-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
$0.00 | $0.00 | Q:9 /30Days | $1,029.87 |
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 Balanced Medicaid Advantage (HMO D-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
$0.00 | $0.00 | None | $1,027.80 |
Browse Plan Formulary |
Integra Harmony (HMO D-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
15% | 15% | None | $1,027.80 |
Browse Plan Formulary |
Integra Synergy Medicaid Advantage Plus (MAP) (HMO D-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
$0.00 | $0.00 | None | $1,027.80 |
Browse Plan Formulary |
Longevity Health Plan (HMO I-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
25% | n/a | Q:9 /30Days | $1,012.05 |
Browse Plan Formulary |
MetroPlus Advantage Plan (HMO D-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
15% | 15% | Q:9 /30Days | $988.11 |
Browse Plan Formulary |
MetroPlus UltraCare (HMO D-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
$0.00 | $0.00 | Q:9 /30Days | $988.11 |
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:9 /30Days | $1,005.30 |
Browse Plan Formulary |
RiverSpring Star (HMO I-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
25% | 25% | Q:9 /30Days | $1,005.30 |
Browse Plan Formulary |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$42.30 |
$200* | No | 3* |
Preferred Brand |
$47.00 | $131.00 | Q:9 /30Days | $1,084.23 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$42.30 |
$445 | No | 3 |
Tier 3 |
$0.00 | $0.00 | Q:9 /30Days | $1,084.14 |
Browse Plan Formulary |
VillageCareMAX Medicare Health Advantage (HMO D-SNP)
|
$42.30 |
$445 | No | 1 |
Tier 1 |
15% | 15% | Q:9 /30Days | $986.58 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO D-SNP)
|
$42.30 |
$445 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:9 /30Days | $1,014.03 |
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 4 (Regional PPO)
|
$43.70 |
$150 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:9 /30Days | $1,084.14 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Plan 1 (HMO)
|
$54.00 |
$395 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:9 /30Days | $1,084.59 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Bright Advantage Plus (HMO)
|
$59.00 |
$445 | No | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:9 /28Days | $1,028.07 |
Browse Plan Formulary |
EmblemHealth VIP Go (HMO-POS)
|
$72.00 |
$250 | No | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:9 /30Days | $989.73 |
Browse Plan Formulary |
EmblemHealth VIP Go (HMO-POS)
|
$72.00 |
$250 | No | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:9 /30Days | $993.60 |
Browse Plan Formulary |
WellCare Preferred (HMO)
|
$81.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:9 /30Days | $1,073.70 |
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 |
Bright Advantage Choice Plus (PPO)
|
$95.00 |
$445 | No | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:9 /28Days | $1,028.07 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$96.00 |
$200 | No | 3 |
Preferred Brand |
$40.00 | $120.00 | Q:9 /30Days | $984.69 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$96.00 |
$200 | No | 3 |
Preferred Brand |
$40.00 | $120.00 | Q:9 /30Days | $997.29 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$96.00 |
$200 | No | 3 |
Preferred Brand |
$40.00 | $120.00 | Q:9 /30Days | $993.60 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$96.00 |
$200 | No | 3 |
Preferred Brand |
$40.00 | $120.00 | Q:9 /30Days | $992.52 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$99.00 |
$200 | No | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:9 /30Days | $1,072.89 |
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 |
Centers Plan for Medicaid Advantage (HMO D-SNP)
|
$101.00 |
$445 | No | 1 |
Tier 1 |
$0.00 | $0.00 | Q:9 /30Days | $1,025.55 |
Browse Plan Formulary |
Centers Plan for Medicaid Advantage Plus (HMO D-SNP)
|
$101.00 |
$445 | No | 1 |
Tier 1 |
$0.00 | $0.00 | Q:9 /30Days | $1,025.91 |
Browse Plan Formulary |
Empire MediBlue Choice (HMO-POS)
|
$105.00 |
$350 | No | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:9 /30Days | $1,070.01 |
Browse Plan Formulary |
VillageCareMAX Medicare Total Advantage (HMO D-SNP)
|
$116.00 |
$445 | No | 1 |
Tier 1 |
$0.00 | $0.00 | Q:9 /30Days | $986.58 |
Browse Plan Formulary |
MetroPlus Platinum Plan (HMO)
|
$148.50 |
$445 | No | 1 |
Tier 1 |
25% | 25% | Q:9 /30Days | $988.11 |
Browse Plan Formulary |
EmblemHealth VIP Gold Plus (HMO)
|
$302.00 |
$200 | No | 3 |
Preferred Brand |
$40.00 | $120.00 | Q:9 /30Days | $988.83 |
Browse Plan Formulary |