EMSAM TRANSDERMAL SYSTEM PATCHES 9MG/24H (30 PATCHES CRTN) (NDC: 49502090130)
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 Plan 1 (HMO)
|
$0.00 |
$395 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
26% | n/a | Q:30 /30Days | $2,037.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Credit Plan (PPO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
27% | n/a | P Q:30 /30Days | $2,061.90 |
Browse Plan Formulary |
Aetna Medicare Elite Plan (PPO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | P Q:30 /30Days | $2,061.90 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO-POS)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | P Q:30 /30Days | $2,061.90 |
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 | P Q:30 /30Days | $1,865.70 |
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 |
Healthfirst Signature (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
26% | 26% | P Q:30 /30Days | $2,016.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5970-015 (PPO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | P Q:30 /30Days | $2,072.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5970-018 (PPO)
|
$0.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | n/a | P Q:30 /30Days | $2,072.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MVP Medicare WellSelect with Part D (PPO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | n/a | None | $1,857.00 |
Browse Plan Formulary |
Oscar Easy Care (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $2,007.30 |
Browse Plan Formulary |
Wellcare Giveback Open (PPO)
|
$0.00 |
$325 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
27% | n/a | P Q:30 /30Days | $2,019.90 |
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 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $2,020.20 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $2,019.90 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO)
|
$16.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | Q:30 /30Days | $2,036.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5970-001 (PPO)
|
$17.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $2,075.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice SNP-DE H5970-020 (PPO D-SNP)
|
$19.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $2,074.50 |
Browse Plan Formulary |
Wellcare Fidelis Dual Access (HMO D-SNP)
|
$20.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $2,016.90 |
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 Fidelis Dual Plus (HMO D-SNP)
|
$23.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $2,017.50 |
Browse Plan Formulary |
Aetna Medicare Assure Plan (HMO D-SNP)
|
$23.80 |
$425 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $2,061.90 |
Browse Plan Formulary |
Empire MediBlue HealthPlus (HMO)
|
$25.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
29% | n/a | P Q:30 /30Days | $2,066.40 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H3533-002 (HMO D-SNP)
|
$30.10 |
$460 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $2,074.50 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
|
$30.80 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $2,016.90 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice Plan 3 (Regional PPO)
|
$34.20 |
$250 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | Q:30 /30Days | $2,036.40 |
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 |
EmblemHealth VIP Passport (HMO)
|
$34.40 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:30 /30Days | $1,868.40 |
Browse Plan Formulary |
Wellcare Dual Access Open (PPO D-SNP)
|
$37.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $2,017.50 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Plan 2 (HMO D-SNP)
|
$37.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | Q:30 /30Days | $2,036.70 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Plan 2 (HMO D-SNP)
|
$37.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | Q:30 /30Days | $2,036.40 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO D-SNP)
|
$39.90 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days | $2,016.00 |
Browse Plan Formulary |
MVP Medicare Secure with Part D (HMO-POS)
|
$40.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | None | $1,857.00 |
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 Assist (HMO I-SNP)
|
$42.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days | $1,857.00 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)
|
$42.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | Q:30 /30Days | $2,037.00 |
Browse Plan Formulary |
MVP DualAccess (HMO D-SNP)
|
$42.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | None | $1,857.00 |
Browse Plan Formulary |
ArchCare Advantage (HMO I-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days | $1,857.00 |
Browse Plan Formulary |
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 Q:30 /30Days | $1,857.00 |
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 Q:30 /30Days | $1,857.00 |
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 (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | P Q:30 /30Days | $1,876.80 |
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 | P Q:30 /30Days | $1,872.30 |
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 | P Q:30 /30Days | $1,860.90 |
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 | P Q:30 /30Days | $1,865.70 |
Browse Plan Formulary |
EmblemHealth VIP Solutions (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | P Q:30 /30Days | $1,866.60 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage (HMO D-SNP)
|
$42.40 |
$480 |
Some Generics |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $2,071.20 |
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 Dual Advantage Select (HMO D-SNP)
|
$42.40 |
$480 |
Some Generics |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $2,071.20 |
Browse Plan Formulary |
Empire MediBlue HealthPlus Dual Connect (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $2,070.00 |
Browse Plan Formulary |
Empire MediBlue HealthPlus Dual Plus (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $2,070.00 |
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% | S Q:30 /30Days | $1,867.50 |
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% | S Q:30 /30Days | $1,867.80 |
Browse Plan Formulary |
Healthfirst Connection Plan (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days | $2,016.00 |
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 Increased Benefits Plan (HMO)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days | $2,016.00 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days | $2,016.00 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Plan 1 (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | Q:30 /30Days | $2,036.70 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Plan 1 (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | Q:30 /30Days | $2,036.40 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 2 (HMO I-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | Q:30 /30Days | $2,037.30 |
Browse Plan Formulary |
Empire MediBlue Select (HMO)
|
$45.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
29% | n/a | P Q:30 /30Days | $2,067.00 |
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 |
MVP Medicare Patriot Plan with Part D (PPO)
|
$45.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | n/a | None | $1,857.00 |
Browse Plan Formulary |
EmblemHealth VIP Rx Saver (HMO)
|
$49.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:30 /30Days | $1,871.70 |
Browse Plan Formulary |
EmblemHealth VIP Rx Saver (HMO)
|
$49.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:30 /30Days | $1,866.30 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$50.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | P Q:30 /30Days | $2,061.90 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice Plan 4 (Regional PPO)
|
$51.50 |
$150 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
30% | n/a | Q:30 /30Days | $2,036.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
EmblemHealth VIP Essential (HMO)
|
$69.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:30 /30Days | $1,867.50 |
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 |
EmblemHealth VIP Essential (HMO)
|
$69.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:30 /30Days | $1,872.30 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$69.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:30 /30Days | $1,946.70 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$69.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:30 /30Days | $1,860.90 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 2 (HMO)
|
$75.00 |
$295 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
28% | n/a | Q:30 /30Days | $2,037.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MVP Medicare Secure Plus with Part D (HMO-POS)
|
$90.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,857.00 |
Browse Plan Formulary |
MVP Medicare WellSelect Plus with Part D (PPO)
|
$134.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,857.00 |
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 |
MVP Medicare Preferred Gold with Part D (HMO-POS)
|
$140.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,857.00 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$244.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:30 /30Days | $1,864.20 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$244.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:30 /30Days | $1,872.30 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$244.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:30 /30Days | $1,946.70 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$244.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:30 /30Days | $1,860.90 |
Browse Plan Formulary |
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 | P Q:30 /30Days | $1,865.70 |
Browse Plan Formulary |