AMNESTEEM 40 MG CAPSULE [ZENATANE] (60 capsules ) (NDC: 00378661493)
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 |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $596.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Prime (HMO)
|
$0.00 |
$295 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $596.40 |
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. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $111.60 |
Browse Plan Formulary |
Bright Advantage (HMO)
|
$0.00 |
$445 |
No |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $361.80 |
Browse Plan Formulary |
Bright Advantage Choice (PPO)
|
$0.00 |
$445 |
No |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $361.80 |
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 |
Bright Advantage Senior Savings (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None | $361.80 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$295* |
No |
2* |
Generic |
$15.00 | $38.00 | None | $211.20 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$295* |
No |
2* |
Generic |
$15.00 | $38.00 | None | $216.00 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$295* |
No |
2* |
Generic |
$15.00 | $38.00 | None | $211.20 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$295* |
No |
2* |
Generic |
$15.00 | $38.00 | None | $224.40 |
Browse Plan Formulary |
EmblemHealth VIP Part B Saver (HMO)
|
$0.00 |
$445 |
No |
2 |
Generic |
$15.00 | $38.00 | None | $217.20 |
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 |
EmblemHealth VIP Reserve (HMO)
|
$0.00 |
$295* |
No |
2* |
Generic |
$15.00 | $38.00 | None | $216.00 |
Browse Plan Formulary |
EmblemHealth VIP Value (HMO)
|
$0.00 |
$295* |
No |
2* |
Generic |
$15.00 | $38.00 | None | $216.00 |
Browse Plan Formulary |
Empire MediBlue HealthPlus (HMO)
|
$0.00 |
$350 |
No |
4 |
Non-Preferred Drug |
$94.00 | $282.00 | None | $152.40 |
Browse Plan Formulary |
Empire MediBlue Select (HMO)
|
$0.00 |
$350 |
No |
4 |
Non-Preferred Drug |
$94.00 | $282.00 | None | $152.40 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$350 |
No |
4 |
Non-Preferred Drug |
$100.00 | $100.00 | P | $112.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Healthfirst Signature (HMO)
|
$0.00 |
$350 |
No |
4 |
Non-Preferred Drug |
$100.00 | $100.00 | P | $112.20 |
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 |
Humana Gold Plus H3533-027 (HMO)
|
$0.00 |
$400 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:120 /30Days | $171.60 |
Browse Plan Formulary |
Humana Gold Plus H3533-033 (HMO)
|
$0.00 |
$350 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:120 /30Days | $171.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5970-024 (PPO)
|
$0.00 |
$350 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:120 /30Days | $171.60 |
Browse Plan Formulary |
HumanaChoice H5970-024 (PPO)
|
$0.00 |
$350 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:120 /30Days | $171.60 |
Browse Plan Formulary |
WellCare Absolute (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | P | $450.00 |
Browse Plan Formulary |
WellCare Choice (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
48% | 48% | P | $318.00 |
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 Element (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
48% | 48% | P | $350.40 |
Browse Plan Formulary |
WellCare Today's Options Advantage Plus 550B (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | P | $99.60 |
Browse Plan Formulary |
WellCare Summit (PPO)
|
$5.10 |
$445 |
No |
4 |
Non-Preferred Drug |
50% | 50% | P | $454.20 |
Browse Plan Formulary |
WellCare Compass (HMO)
|
$12.30 |
$445 |
No |
4 |
Non-Preferred Drug |
50% | 50% | P | $318.00 |
Browse Plan Formulary |
WellCare Imperial (PPO D-SNP)
|
$12.50 |
$445 |
No |
4 |
Non-Preferred Drug |
49% | 49% | P | $429.60 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$16.00 |
$350 |
No |
4 |
Non-Preferred Drug |
$94.00 | $282.00 | None | $278.40 |
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 |
Empire MediBlue Plus (HMO)
|
$16.00 |
$350 |
No |
4 |
Non-Preferred Drug |
$94.00 | $282.00 | None | $112.80 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$16.00 |
$350 |
No |
4 |
Non-Preferred Drug |
$94.00 | $282.00 | None | $195.60 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO)
|
$16.00 |
$300 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $598.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H3533-032 (HMO)
|
$21.00 |
$200 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:120 /30Days | $171.60 |
Browse Plan Formulary |
Humana Gold Plus H3533-032 (HMO)
|
$21.00 |
$200 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:120 /30Days | $171.60 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO D-SNP)
|
$21.60 |
$445 |
No |
2 |
Generic |
$10.00 | $20.00 | P | $174.00 |
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 |
Aetna Medicare Value Plan (PPO)
|
$22.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $118.20 |
Browse Plan Formulary |
Fidelis Medicaid Advantage Plus (HMO D-SNP)
|
$22.30 |
$445 |
No |
2 |
Generic |
$7.00 | $14.00 | P | $169.80 |
Browse Plan Formulary |
Fidelis Dual Advantage (HMO D-SNP)
|
$22.50 |
$445 |
No |
2 |
Generic |
$20.00 | $40.00 | P | $174.00 |
Browse Plan Formulary |
Elderplan Extra Help (HMO)
|
$25.30 |
$445 |
No |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | P | $109.20 |
Browse Plan Formulary |
Aetna Medicare Assure Plan (HMO D-SNP)
|
$25.70 |
$190 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $111.60 |
Browse Plan Formulary |
WellCare Access (HMO D-SNP)
|
$27.10 |
$445 |
No |
4 |
Non-Preferred Drug |
45% | 45% | P | $318.00 |
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 |
Elderplan Plus Long Term Care (HMO D-SNP)
|
$31.80 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | P | $109.80 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)
|
$32.60 |
$445 |
No |
4 |
Tier 4 |
25% | 25% | P | $596.40 |
Browse Plan Formulary |
Bright Advantage Senior Savings Assist (HMO C-SNP)
|
$33.90 |
$0 |
No |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None | $361.80 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
AARP Medicare Advantage Plan 2 (HMO)
|
$34.00 |
$395 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $596.40 |
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% | P | $109.20 |
Browse Plan Formulary |
Elderplan Advantage For Nursing Home Residents (HMO I-SNP)
|
$35.50 |
$445 |
No |
1 |
Tier 1 |
25% | 25% | P | $107.40 |
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 Medicare Advantage Choice Plan 3 (Regional PPO)
|
$35.60 |
$275 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $598.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Nursing Home Plan 2 (HMO I-SNP)
|
$35.90 |
$445 |
No |
4 |
Tier 4 |
25% | 25% | P | $596.40 |
Browse Plan Formulary |
Aetna Medicare Elite Plan (HMO)
|
$39.00 |
$300 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $121.80 |
Browse Plan Formulary |
Aetna Medicare Elite Plan 3 (PPO)
|
$39.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $114.00 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H3533-031 (HMO D-SNP)
|
$40.30 |
$435 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:120 /30Days | $171.60 |
Browse Plan Formulary |
AgeWell New York Advantage Plus (HMO D-SNP)
|
$42.30 |
$445 |
No |
4 |
Tier 4 |
$0.00 | $0.00 | None | $1,170.60 |
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 |
AgeWell New York CareWell (HMO I-SNP)
|
$42.30 |
$445 |
No |
4 |
Tier 4 |
25% | 25% | None | $1,184.40 |
Browse Plan Formulary |
AgeWell New York FeelWell (HMO D-SNP)
|
$42.30 |
$445 |
No |
4 |
Tier 4 |
$0.00 | $0.00 | None | $1,170.60 |
Browse Plan Formulary |
AgeWell New York LiveWell (HMO)
|
$42.30 |
$350 |
No |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | None | $1,170.60 |
Browse Plan Formulary |
ArchCare Advantage (HMO I-SNP)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
25% | 25% | P | $116.40 |
Browse Plan Formulary |
Bright Advantage Assist (HMO)
|
$42.30 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | None | $361.80 |
Browse Plan Formulary |
Bright Advantage Special Care (HMO D-SNP)
|
$42.30 |
$445 |
No |
4 |
Tier 4 |
$0.00 | $0.00 | None | $361.80 |
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 |
Elderplan Assist (HMO I-SNP)
|
$42.30 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | P | $107.40 |
Browse Plan Formulary |
EmblemHealth VIP Assist (HMO D-SNP)
|
$42.30 |
$445 |
No |
2 |
Tier 2 |
$0.00 | $0.00 | None | $217.20 |
Browse Plan Formulary |
EmblemHealth VIP Connect (HMO D-SNP)
|
$42.30 |
$445 |
No |
2 |
Tier 2 |
$0.00 | $0.00 | None | $217.20 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
|
$42.30 |
$445 |
No |
2 |
Tier 2 |
$0.00 | $0.00 | None | $213.60 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
|
$42.30 |
$445 |
No |
2 |
Tier 2 |
$0.00 | $0.00 | None | $224.40 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
|
$42.30 |
$445 |
No |
2 |
Tier 2 |
$0.00 | $0.00 | None | $216.00 |
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 Dual Reserve (HMO D-SNP)
|
$42.30 |
$445 |
No |
2 |
Tier 2 |
$0.00 | $0.00 | None | $216.00 |
Browse Plan Formulary |
EmblemHealth VIP Dual Select (HMO D-SNP)
|
$42.30 |
$445 |
No |
2 |
Tier 2 |
$0.00 | $0.00 | None | $217.20 |
Browse Plan Formulary |
EmblemHealth VIP Passport NYC (HMO)
|
$42.30 |
$295* |
No |
2* |
Generic |
$15.00 | $38.00 | None | $214.80 |
Browse Plan Formulary |
EmblemHealth VIP Solutions (HMO D-SNP)
|
$42.30 |
$445 |
No |
2 |
Tier 2 |
15% | 15% | None | $217.20 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage (HMO D-SNP)
|
$42.30 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $152.40 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage Select (HMO D-SNP)
|
$42.30 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $151.20 |
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 Extra Select (HMO)
|
$42.30 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $152.40 |
Browse Plan Formulary |
Empire MediBlue HealthPlus Dual Advantage (HMO D-SNP)
|
$42.30 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $178.20 |
Browse Plan Formulary |
Empire MediBlue HealthPlus Dual Connect (HMO D-SNP)
|
$42.30 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $178.20 |
Browse Plan Formulary |
Empire MediBlue HealthPlus Dual Plus (HMO D-SNP)
|
$42.30 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $178.20 |
Browse Plan Formulary |
Hamaspik Medicare Choice (HMO D-SNP)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | P | $308.40 |
Browse Plan Formulary |
Hamaspik Medicare Select (HMO D-SNP)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | P | $312.00 |
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 |
Healthfirst CompleteCare (HMO D-SNP)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | P | $112.80 |
Browse Plan Formulary |
Healthfirst Increased Benefits Plan (HMO)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
25% | 25% | P | $112.80 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO D-SNP)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | P | $112.80 |
Browse Plan Formulary |
Integra Balanced Medicaid Advantage (HMO D-SNP)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | None | $1,170.60 |
Browse Plan Formulary |
Integra Harmony (HMO D-SNP)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | None | $1,170.60 |
Browse Plan Formulary |
Integra Synergy Medicaid Advantage Plus (MAP) (HMO D-SNP)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | None | $1,170.60 |
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 |
Longevity Health Plan (HMO I-SNP)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
25% | n/a | None | $287.40 |
Browse Plan Formulary |
MetroPlus Advantage Plan (HMO D-SNP)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | P | $162.60 |
Browse Plan Formulary |
MetroPlus UltraCare (HMO D-SNP)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
$0.00 | $0.00 | P | $162.60 |
Browse Plan Formulary |
RiverSpring MAP (HMO D-SNP)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
15% | 15% | P | $1,219.80 |
Browse Plan Formulary |
RiverSpring Star (HMO I-SNP)
|
$42.30 |
$445 |
No |
1 |
Tier 1 |
25% | 25% | P | $1,219.80 |
Browse Plan Formulary |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$42.30 |
$200 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $597.00 |
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 |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$42.30 |
$445 |
No |
4 |
Tier 4 |
$0.00 | $0.00 | P | $598.20 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice Plan 4 (Regional PPO)
|
$43.70 |
$150 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $598.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Plan 1 (HMO)
|
$54.00 |
$395 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $596.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Bright Advantage Plus (HMO)
|
$59.00 |
$445 |
No |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $361.80 |
Browse Plan Formulary |
EmblemHealth VIP Go (HMO-POS)
|
$72.00 |
$250* |
No |
2* |
Generic |
$15.00 | $38.00 | None | $224.40 |
Browse Plan Formulary |
EmblemHealth VIP Go (HMO-POS)
|
$72.00 |
$250* |
No |
2* |
Generic |
$15.00 | $38.00 | None | $215.40 |
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 |
WellCare Preferred (HMO)
|
$81.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | P | $318.00 |
Browse Plan Formulary |
Bright Advantage Choice Plus (PPO)
|
$95.00 |
$445 |
No |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $361.80 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$96.00 |
$200* |
No |
2* |
Generic |
$10.00 | $25.00 | None | $211.20 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$96.00 |
$200* |
No |
2* |
Generic |
$10.00 | $25.00 | None | $224.40 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$96.00 |
$200* |
No |
2* |
Generic |
$10.00 | $25.00 | None | $211.20 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$96.00 |
$200* |
No |
2* |
Generic |
$10.00 | $25.00 | None | $216.00 |
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 |
Aetna Medicare Premier Plan (PPO)
|
$99.00 |
$200 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $114.00 |
Browse Plan Formulary |
WellCare Today's Options Advantage Plus 150A (PPO)
|
$121.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$75.00 | $150.00 | P | $100.20 |
Browse Plan Formulary |
MetroPlus Platinum Plan (HMO)
|
$148.50 |
$445 |
No |
1 |
Tier 1 |
25% | 25% | P | $162.60 |
Browse Plan Formulary |
EmblemHealth VIP Gold Plus (HMO)
|
$302.00 |
$200* |
No |
2* |
Generic |
$10.00 | $25.00 | None | $217.20 |
Browse Plan Formulary |