ACITRETIN 25 MG CAPSULE [Soriatane] (30 CAPSULES ) (NDC: 42794008308)
2022 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 |
$300 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $171.60 |
Browse Plan Formulary |
Centers Plan for Medicare Advantage Care (HMO)
|
$0.00 |
$395* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | $37.50 | None | $385.20 |
Browse Plan Formulary |
EmblemHealth VIP Value (HMO)
|
$0.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $420.30 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$295 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $341.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Healthfirst Signature (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $341.40 |
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 |
$425 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $454.50 |
Browse Plan Formulary |
HumanaChoice H5970-024 (PPO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $454.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5970-024 (PPO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $454.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
PHP Care Complete FIDA-IDD Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
All Generics, All Brands |
1 |
Tier 1 |
0% | 0% | None | $278.70 |
Browse Plan Formulary |
Wellcare Giveback Open (PPO)
|
$0.00 |
$325 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
48% | 48% | P | $626.40 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | P | $614.10 |
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 No Premium Open (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
42% | 42% | P | $626.40 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO)
|
$16.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $420.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Fidelis Dual Plus (HMO D-SNP)
|
$18.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $0.00 | P | $612.00 |
Browse Plan Formulary |
Wellcare Fidelis Dual Access (HMO D-SNP)
|
$20.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $0.00 | P | $576.30 |
Browse Plan Formulary |
Aetna Medicare Assure Plan (HMO D-SNP)
|
$23.20 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $172.50 |
Browse Plan Formulary |
Empire MediBlue HealthPlus (HMO)
|
$25.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$94.00 | $282.00 | None | $372.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
VNSNY CHOICE EasyCare (HMO)
|
$25.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $60.00 | None | $278.70 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
|
$27.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
42% | 42% | P | $544.80 |
Browse Plan Formulary |
Wellcare Assist Open (PPO)
|
$30.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
44% | 44% | P | $696.30 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice Plan 3 (Regional PPO)
|
$34.20 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $420.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
EmblemHealth VIP Passport (HMO)
|
$34.40 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $420.30 |
Browse Plan Formulary |
Longevity Health Plan (HMO I-SNP)
|
$36.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $286.80 |
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 |
Aetna Medicare Premier Plus Plan (PPO)
|
$37.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $104.70 |
Browse Plan Formulary |
Wellcare Dual Access Open (PPO D-SNP)
|
$37.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
49% | 49% | P | $699.00 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Plan 2 (HMO D-SNP)
|
$37.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $458.40 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Plan 2 (HMO D-SNP)
|
$37.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $396.90 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H3533-034 (HMO D-SNP)
|
$38.90 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $454.50 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H3533-034 (HMO D-SNP)
|
$38.90 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $454.50 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Plus H3533-010 (HMO)
|
$39.60 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $454.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Elderplan For Medicaid Beneficiaries (HMO D-SNP)
|
$39.90 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P | $315.90 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO D-SNP)
|
$39.90 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | P | $339.30 |
Browse Plan Formulary |
Elderplan Assist (HMO I-SNP)
|
$42.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | P | $315.90 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)
|
$42.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $450.60 |
Browse Plan Formulary |
AgeWell New York Advantage Plus (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | P | $468.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
AgeWell New York CareWell (HMO I-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | P | $510.90 |
Browse Plan Formulary |
AgeWell New York FeelWell (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | P | $468.30 |
Browse Plan Formulary |
AgeWell New York LiveWell (HMO)
|
$42.40 |
$350 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | P | $468.30 |
Browse Plan Formulary |
Centers Plan for Dual Coverage Care (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $431.10 |
Browse Plan Formulary |
Centers Plan for Medicaid Advantage Plus (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $410.40 |
Browse Plan Formulary |
Centers Plan for Nursing Home Care (HMO I-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $383.40 |
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 |
Elderplan Advantage For Nursing Home Residents (HMO I-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | P | $315.90 |
Browse Plan Formulary |
Elderplan Plus Long Term Care (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P | $315.90 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $417.90 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $418.20 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $421.50 |
Browse Plan Formulary |
EmblemHealth VIP Dual Select (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $419.10 |
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)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $419.10 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage (HMO D-SNP)
|
$42.40 |
$480 |
Some Generics |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $322.20 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage Select (HMO D-SNP)
|
$42.40 |
$480 |
Some Generics |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $327.60 |
Browse Plan Formulary |
Empire MediBlue HealthPlus Dual Connect (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $335.10 |
Browse Plan Formulary |
Empire MediBlue HealthPlus Dual Plus (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $335.10 |
Browse Plan Formulary |
Hamaspik Medicare Choice (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $395.40 |
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 |
Hamaspik Medicare Select (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $409.20 |
Browse Plan Formulary |
Healthfirst Connection Plan (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P | $339.30 |
Browse Plan Formulary |
Healthfirst Increased Benefits Plan (HMO)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P | $339.30 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
42% | 42% | P | $339.30 |
Browse Plan Formulary |
Integra Harmony (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P | $843.00 |
Browse Plan Formulary |
Integra Synergy Medicaid Advantage Plus (MAP) (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P | $843.00 |
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 |
RiverSpring MAP (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P | $605.10 |
Browse Plan Formulary |
RiverSpring Star (HMO I-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | P | $605.10 |
Browse Plan Formulary |
Senior Whole Health Medicare Complete Care (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P | $865.20 |
Browse Plan Formulary |
Senior Whole Health of New York NHC (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P | $865.20 |
Browse Plan Formulary |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$42.40 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $436.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Dual Complete Plan 1 (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $458.40 |
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 Dual Complete Plan 1 (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $396.90 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 2 (HMO I-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $467.10 |
Browse Plan Formulary |
VNSNY CHOICE EasyCare Plus (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $278.70 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $60.00 | None | $278.70 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$51.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $359.70 |
Browse Plan Formulary |
Empire MediBlue Select (HMO)
|
$51.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$94.00 | $282.00 | None | $359.70 |
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 |
UnitedHealthcare Medicare Advantage Choice Plan 4 (Regional PPO)
|
$51.50 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $420.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
EmblemHealth VIP Essential (HMO)
|
$55.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $424.80 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$55.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $417.90 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$55.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $421.20 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$55.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $418.20 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$89.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $104.70 |
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 |
Aetna Medicare Premier Plan (PPO)
|
$99.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $165.90 |
Browse Plan Formulary |
Wellcare Premium Ultra Open (PPO)
|
$121.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
43% | 43% | P | $602.70 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$124.50 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $422.70 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$124.50 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $417.90 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$124.50 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $421.20 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$124.50 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $418.20 |
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 Gold Plus (HMO)
|
$261.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $419.10 |
Browse Plan Formulary |