GLATIRAMER 20 MG/ML SYRINGE [Glatopa] (mls ) (NDC: 00378696093)
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. |
5 |
Specialty Tier |
28% | n/a | Q:30 /30Days | $4,544.70 |
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. |
5 |
Specialty Tier |
28% | n/a | Q:30 /30Days | $4,544.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Bright Advantage Classic Care Plan (HMO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,979.70 |
Browse Plan Formulary |
Bright Advantage Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $1,979.70 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Centers Plan for Medicare Advantage Care (HMO)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,979.70 |
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 |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | n/a | None | $4,252.80 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | n/a | None | $5,356.50 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | n/a | None | $4,918.80 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$0.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | n/a | None | $4,727.70 |
Browse Plan Formulary |
EmblemHealth VIP Reserve (HMO)
|
$0.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | n/a | None | $4,727.70 |
Browse Plan Formulary |
EmblemHealth VIP Value (HMO)
|
$0.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | n/a | None | $4,878.90 |
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 |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$295 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
26% | 26% | P Q:30 /30Days | $4,869.30 |
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 |
5 |
Specialty Tier |
26% | 26% | P Q:30 /30Days | $4,869.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H3533-027 (HMO)
|
$0.00 |
$425 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $2,460.00 |
Browse Plan Formulary |
Humana Gold Plus H3533-033 (HMO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
27% | n/a | P Q:30 /30Days | $2,460.00 |
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 |
5 |
Specialty Tier |
27% | n/a | P Q:30 /30Days | $2,460.00 |
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 |
5 |
Specialty Tier |
27% | n/a | P Q:30 /30Days | $2,460.00 |
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 |
PHP Care Complete FIDA-IDD Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
All Generics, All Brands |
2 |
Tier 2 |
0% | 0% | P Q:30 /30Days | $1,979.70 |
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 | $4,869.30 |
Browse Plan Formulary |
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 | $4,869.30 |
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 | $4,869.30 |
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 | $4,625.70 |
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 |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $3,999.90 |
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 Assist (HMO)
|
$19.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $4,869.30 |
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 | $4,029.30 |
Browse Plan Formulary |
Humana Gold Plus H3533-032 (HMO)
|
$24.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | P Q:30 /30Days | $2,452.20 |
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 |
5 |
Specialty Tier |
29% | n/a | P Q:30 /30Days | $2,460.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
VNSNY CHOICE EasyCare (HMO)
|
$25.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,979.70 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
|
$27.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $4,869.30 |
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 |
Wellcare Assist Open (PPO)
|
$30.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $4,869.30 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 2 (HMO)
|
$34.00 |
$395 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
26% | n/a | Q:30 /30Days | $4,544.70 |
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. |
5 |
Specialty Tier |
28% | n/a | Q:30 /30Days | $4,625.70 |
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 |
5 |
Specialty Tier |
27% | n/a | None | $4,727.70 |
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 | P Q:30 /30Days | $4,951.80 |
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 | $4,869.30 |
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 |
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 | $4,771.80 |
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 | $4,495.50 |
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 |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $2,460.00 |
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 |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $2,460.00 |
Browse Plan Formulary |
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 Q:30 /30Days | $4,869.30 |
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 | $4,869.30 |
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 |
Bright Advantage Embrace Choice Plan (HMO C-SNP)
|
$41.60 |
$480 |
Some Generics |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,979.70 |
Browse Plan Formulary |
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 | $4,869.30 |
Browse Plan Formulary |
Elderplan Extra Help (HMO)
|
$42.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days | $4,869.30 |
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 | $4,764.30 |
Browse Plan Formulary |
AgeWell New York Advantage Plus (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P | $2,543.70 |
Browse Plan Formulary |
AgeWell New York CareWell (HMO I-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $2,540.10 |
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 |
AgeWell New York FeelWell (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P | $2,543.70 |
Browse Plan Formulary |
AgeWell New York LiveWell (HMO)
|
$42.40 |
$350 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
27% | 27% | P | $2,543.70 |
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 | $4,869.30 |
Browse Plan Formulary |
Bright Advantage Dual Access Plan (HMO D-SNP)
|
$42.40 |
$480 |
Some Generics |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,979.70 |
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% | P Q:30 /30Days | $1,979.70 |
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 | P Q:30 /30Days | $1,979.70 |
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 |
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% | P Q:30 /30Days | $2,306.10 |
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 | $4,869.30 |
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 | $4,869.30 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | None | $4,878.90 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | None | $5,356.50 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | None | $4,727.70 |
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 |
EmblemHealth VIP Dual Reserve (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | None | $4,727.70 |
Browse Plan Formulary |
EmblemHealth VIP Dual Select (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | None | $4,853.40 |
Browse Plan Formulary |
EmblemHealth VIP Solutions (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | None | $4,879.20 |
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% | P Q:30 /30Days | $1,808.10 |
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% | P Q:30 /30Days | $1,794.60 |
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 | $4,869.30 |
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 |
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 | $4,869.30 |
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 | $4,869.30 |
Browse Plan Formulary |
MetroPlus Advantage Plan (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P Q:30 /30Days | $4,869.30 |
Browse Plan Formulary |
MetroPlus UltraCare (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P Q:30 /30Days | $4,869.30 |
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:30 /30Days | $4,246.20 |
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 Q:30 /30Days | $4,246.20 |
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 |
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 Q:30 /30Days | $3,411.00 |
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 Q:30 /30Days | $3,411.00 |
Browse Plan Formulary |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
|
$42.40 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | Q:30 /30Days | $4,757.70 |
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 |
5 |
Tier 5 |
$0.00 | $0.00 | Q:30 /30Days | $4,771.80 |
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 | $4,495.50 |
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 | $4,773.60 |
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 |
VillageCareMAX Medicare Health Advantage (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P Q:30 /30Days | $1,979.70 |
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% | P Q:30 /30Days | $1,979.70 |
Browse Plan Formulary |
VNSNY CHOICE Total (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 | $1,979.70 |
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 | $4,625.70 |
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. |
5 |
Specialty Tier |
26% | n/a | Q:30 /30Days | $4,544.70 |
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. |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $1,979.70 |
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 |
EmblemHealth VIP Gold (HMO)
|
$97.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | None | $4,252.80 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$97.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | None | $5,356.50 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$97.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | None | $4,918.80 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$97.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | None | $4,727.70 |
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 | P Q:30 /30Days | $1,979.70 |
Browse Plan Formulary |
Wellcare Premium Ultra Open (PPO)
|
$121.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $4,869.30 |
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 |
MetroPlus Platinum Plan (HMO)
|
$149.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days | $4,869.30 |
Browse Plan Formulary |
EmblemHealth VIP Gold Plus (HMO)
|
$261.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | None | $4,853.40 |
Browse Plan Formulary |