CALCIPOTRIENE 0.005% CREAM (G) [Dovonex] (60 GRAMS ) (NDC: 68462050166)
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 |
AARP Medicare Advantage Mosaic Choice (PPO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:120 /30Days | $94.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Prime (HMO)
|
$0.00 |
$295 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:120 /30Days | $94.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Elite Plan (PPO)
|
$0.00 |
$300 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:120 /30Days | $103.80 |
Browse Plan Formulary |
Bright Advantage Classic Care Plan (HMO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:120 /30Days | $79.20 |
Browse Plan Formulary |
Bright Advantage Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 | Some Generics | 4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:120 /30Days | $79.20 |
Browse Plan Formulary select insulin pay $0-$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 |
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 | Q:120 /30Days | $113.40 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$325* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | $0.00 | Q:120 /30Days | $91.20 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$325* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | $0.00 | Q:120 /30Days | $83.40 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$325* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | $0.00 | Q:120 /30Days | $84.00 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$325* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | $0.00 | Q:120 /30Days | $83.40 |
Browse Plan Formulary |
EmblemHealth VIP Reserve (HMO)
|
$0.00 |
$325* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | $0.00 | Q:120 /30Days | $83.40 |
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 Value (HMO)
|
$0.00 |
$325* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | $0.00 | Q:120 /30Days | $84.60 |
Browse Plan Formulary |
Empire MediBlue HealthPlus (HMO)
|
$0.00 |
$350 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$94.00 | $282.00 | Q:120 /30Days | $60.00 |
Browse Plan Formulary |
Empire MediBlue HealthPlus Select (HMO)
|
$0.00 |
$350 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$94.00 | $282.00 | Q:120 /30Days | $59.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Empire MediBlue Select (HMO)
|
$0.00 |
$350 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$94.00 | $282.00 | Q:120 /30Days | $60.00 |
Browse Plan Formulary |
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 Q:120 /30Days | $91.20 |
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 Q:120 /30Days | $90.60 |
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 |
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 Q:120 /30Days | $96.00 |
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% | Q:120 /30Days | $79.20 |
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 | Q:120 /30Days | $90.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Assure Plan (HMO D-SNP)
|
$23.20 |
$400 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
25% | 25% | P Q:120 /30Days | $172.80 |
Browse Plan Formulary |
Humana Gold Plus H3533-032 (HMO)
|
$24.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:120 /30Days | $93.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H3533-032 (HMO)
|
$24.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:120 /30Days | $90.60 |
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 |
Aetna Medicare Elite Plan 3 (PPO)
|
$25.00 |
$300 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:120 /30Days | $94.80 |
Browse Plan Formulary |
VNSNY CHOICE EasyCare (HMO)
|
$25.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $60.00 | Q:120 /30Days | $79.20 |
Browse Plan Formulary |
Aetna Medicare Discover Value Plan (PPO)
|
$26.00 |
$300 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:120 /30Days | $95.40 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 2 (HMO)
|
$34.00 |
$395 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:120 /30Days | $94.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
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 | Q:120 /30Days | $90.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
EmblemHealth VIP Passport NYC (HMO)
|
$34.90 |
$350* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | $0.00 | Q:120 /30Days | $83.40 |
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 Extra Select (HMO)
|
$36.60 |
$480 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:120 /30Days | $60.00 |
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 | Q:120 /30Days | $68.40 |
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 | Q:120 /30Days | $84.60 |
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 | Q:120 /30Days | $94.20 |
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 Q:120 /30Days | $93.00 |
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 Q:120 /30Days | $90.60 |
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 |
Aetna Medicare Elite Plan (HMO)
|
$39.00 |
$300 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:120 /30Days | $94.20 |
Browse Plan Formulary |
Bright Advantage Embrace Choice Plan (HMO C-SNP)
|
$41.60 |
$480 | Some Generics | 4 |
Non-Preferred Drug |
25% | 25% | Q:120 /30Days | $79.20 |
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% | Q:120 /30Days | $93.60 |
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 | Q:120 /30Days | $76.20 |
Browse Plan Formulary |
AgeWell New York CareWell (HMO I-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | Q:120 /30Days | $84.00 |
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 | Q:120 /30Days | $76.20 |
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 |
AgeWell New York LiveWell (HMO)
|
$42.40 |
$350 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $250.00 | Q:120 /30Days | $76.20 |
Browse Plan Formulary |
Bright Advantage Dual Access Plan (HMO D-SNP)
|
$42.40 |
$480 | Some Generics | 4 |
Non-Preferred Drug |
25% | 25% | Q:120 /30Days | $79.20 |
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% | Q:120 /30Days | $107.40 |
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 | Q:120 /30Days | $108.00 |
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% | Q:120 /30Days | $115.20 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | Q:120 /30Days | $83.40 |
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 Dual (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | Q:120 /30Days | $84.00 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | Q:120 /30Days | $93.00 |
Browse Plan Formulary |
EmblemHealth VIP Dual Reserve (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | Q:120 /30Days | $83.40 |
Browse Plan Formulary |
EmblemHealth VIP Dual Select (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | Q:120 /30Days | $84.60 |
Browse Plan Formulary |
EmblemHealth VIP Solutions (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | Q:120 /30Days | $86.40 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage (HMO D-SNP)
|
$42.40 |
$480 | Some Generics | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:120 /30Days | $60.60 |
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 |
Empire MediBlue Dual Advantage Select (HMO D-SNP)
|
$42.40 |
$480 | Some Generics | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:120 /30Days | $61.20 |
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 | Q:120 /30Days | $61.80 |
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 | Q:120 /30Days | $61.80 |
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% | Q:120 /30Days | $94.80 |
Browse Plan Formulary |
Hamaspik Medicare Select (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | Q:120 /30Days | $97.80 |
Browse Plan Formulary |
RiverSpring MAP (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | P Q:120 /30Days | $429.60 |
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 Star (HMO I-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | P Q:120 /30Days | $429.60 |
Browse Plan Formulary |
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 | Q:120 /30Days | $94.20 |
Browse Plan Formulary |
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 | Q:120 /30Days | $84.60 |
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% | Q:120 /30Days | $94.20 |
Browse Plan Formulary |
VillageCareMAX Medicare Health Advantage (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | Q:120 /30Days | $79.20 |
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% | Q:120 /30Days | $79.20 |
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 |
VNSNY CHOICE Total (HMO D-SNP)
|
$42.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $60.00 | Q:120 /30Days | $79.20 |
Browse Plan Formulary |
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 | Q:120 /30Days | $90.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Plan 1 (HMO)
|
$54.00 |
$395 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:120 /30Days | $94.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Bright Advantage Classic Plus Plan (HMO)
|
$59.00 |
$480 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:120 /30Days | $79.20 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$97.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $0.00 | Q:120 /30Days | $84.00 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$97.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $0.00 | Q:120 /30Days | $84.00 |
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 Gold (HMO)
|
$97.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $0.00 | Q:120 /30Days | $91.20 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$97.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $0.00 | Q:120 /30Days | $83.40 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$99.00 |
$250 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:120 /30Days | $102.60 |
Browse Plan Formulary |
VillageCareMAX Medicare Total Advantage (HMO D-SNP)
|
$117.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | Q:120 /30Days | $79.20 |
Browse Plan Formulary |
EmblemHealth VIP Gold Plus (HMO)
|
$261.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $0.00 | Q:120 /30Days | $84.60 |
Browse Plan Formulary |