PROLENSA 0.07% EYE DROPS (NDC: 24208060203)
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)
![Email Prescription and/or Health Benefit details for Aetna Medicare Elite Plan (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $342.93 |
Browse Plan Formulary |
Centers Plan for Medicare Advantage Care (HMO)
![Email Prescription and/or Health Benefit details for Centers Plan for Medicare Advantage Care (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $117.50 | None | $320.34 |
Browse Plan Formulary |
EmblemHealth VIP Value (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Value (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $308.82 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
![Email Prescription and/or Health Benefit details for Healthfirst 65 Plus Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$295 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $47.00 | None | $335.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Healthfirst Signature (HMO)
![Email Prescription and/or Health Benefit details for Healthfirst Signature (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $47.00 | None | $335.40 |
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 |
PHP Care Complete FIDA-IDD Plan (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for PHP Care Complete FIDA-IDD Plan (Medicare-Medicaid Plan)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
All Generics, All Brands |
2 |
Tier 2 |
0% | 0% | None | $308.34 |
Browse Plan Formulary |
Wellcare Giveback Open (PPO)
![Email Prescription and/or Health Benefit details for Wellcare Giveback Open (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$325 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $74.00 | None | $336.81 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
![Email Prescription and/or Health Benefit details for Wellcare No Premium (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$37.00 | $74.00 | None | $337.14 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
![Email Prescription and/or Health Benefit details for Wellcare No Premium Open (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $74.00 | None | $336.81 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$16.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $338.91 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Fidelis Dual Plus (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Wellcare Fidelis Dual Plus (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$18.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $335.55 |
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 Access (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Wellcare Fidelis Dual Access (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$20.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $335.55 |
Browse Plan Formulary |
Aetna Medicare Assure Plan (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Aetna Medicare Assure Plan (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$23.20 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $342.93 |
Browse Plan Formulary |
Empire MediBlue HealthPlus (HMO)
![Email Prescription and/or Health Benefit details for Empire MediBlue HealthPlus (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$25.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$94.00 | $282.00 | None | $343.50 |
Browse Plan Formulary |
VNSNY CHOICE EasyCare (HMO)
![Email Prescription and/or Health Benefit details for VNSNY CHOICE EasyCare (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$25.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $309.15 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Wellcare Dual Access (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$27.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $335.58 |
Browse Plan Formulary |
Wellcare Assist Open (PPO)
![Email Prescription and/or Health Benefit details for Wellcare Assist Open (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$30.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $335.52 |
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)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Medicare Advantage Choice Plan 3 (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$34.20 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $338.91 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
EmblemHealth VIP Passport (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Passport (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$34.40 |
$350* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$42.00 | $126.00 | None | $310.32 |
Browse Plan Formulary |
Longevity Health Plan (HMO I-SNP)
![Email Prescription and/or Health Benefit details for Longevity Health Plan (HMO I-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $304.32 |
Browse Plan Formulary |
Aetna Medicare Premier Plus Plan (PPO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Premier Plus Plan (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$37.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $342.63 |
Browse Plan Formulary |
Wellcare Dual Access Open (PPO D-SNP)
![Email Prescription and/or Health Benefit details for Wellcare Dual Access Open (PPO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$37.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $84.00 | None | $335.55 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Plan 2 (HMO D-SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Dual Complete Plan 2 (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$37.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $338.94 |
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)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Dual Complete Plan 2 (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$37.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $338.91 |
Browse Plan Formulary |
Elderplan For Medicaid Beneficiaries (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Elderplan For Medicaid Beneficiaries (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$39.90 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $308.88 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Healthfirst CompleteCare (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$39.90 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $335.40 |
Browse Plan Formulary |
Elderplan Assist (HMO I-SNP)
![Email Prescription and/or Health Benefit details for Elderplan Assist (HMO I-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.00 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $94.00 | None | $308.91 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $338.91 |
Browse Plan Formulary |
Centers Plan for Dual Coverage Care (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Centers Plan for Dual Coverage Care (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $320.22 |
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 Medicaid Advantage Plus (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Centers Plan for Medicaid Advantage Plus (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $320.22 |
Browse Plan Formulary |
Centers Plan for Nursing Home Care (HMO I-SNP)
![Email Prescription and/or Health Benefit details for Centers Plan for Nursing Home Care (HMO I-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $320.37 |
Browse Plan Formulary |
Elderplan Advantage For Nursing Home Residents (HMO I-SNP)
![Email Prescription and/or Health Benefit details for Elderplan Advantage For Nursing Home Residents (HMO I-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $308.91 |
Browse Plan Formulary |
Elderplan Plus Long Term Care (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Elderplan Plus Long Term Care (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $308.91 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Dual (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | None | $310.92 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Dual (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | None | $312.39 |
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)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Dual (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | None | $307.20 |
Browse Plan Formulary |
EmblemHealth VIP Dual Select (HMO D-SNP)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Dual Select (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | None | $308.28 |
Browse Plan Formulary |
EmblemHealth VIP Solutions (HMO D-SNP)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Solutions (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $308.76 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Empire MediBlue Dual Advantage (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.40 |
$480 |
Some Generics |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $344.22 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage Select (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Empire MediBlue Dual Advantage Select (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.40 |
$480 |
Some Generics |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $344.22 |
Browse Plan Formulary |
Empire MediBlue HealthPlus Dual Connect (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Empire MediBlue HealthPlus Dual Connect (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $344.13 |
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 HealthPlus Dual Plus (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Empire MediBlue HealthPlus Dual Plus (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $344.13 |
Browse Plan Formulary |
Hamaspik Medicare Choice (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Hamaspik Medicare Choice (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:12 /365Days | $310.65 |
Browse Plan Formulary |
Hamaspik Medicare Select (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Hamaspik Medicare Select (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:12 /365Days | $310.71 |
Browse Plan Formulary |
Healthfirst Connection Plan (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Healthfirst Connection Plan (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $335.40 |
Browse Plan Formulary |
Healthfirst Increased Benefits Plan (HMO)
![Email Prescription and/or Health Benefit details for Healthfirst Increased Benefits Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $335.40 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Healthfirst Life Improvement Plan (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $335.40 |
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 |
RiverSpring MAP (HMO D-SNP)
![Email Prescription and/or Health Benefit details for RiverSpring MAP (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $311.13 |
Browse Plan Formulary |
RiverSpring Star (HMO I-SNP)
![Email Prescription and/or Health Benefit details for RiverSpring Star (HMO I-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $311.13 |
Browse Plan Formulary |
Senior Whole Health Medicare Complete Care (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Senior Whole Health Medicare Complete Care (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $308.88 |
Browse Plan Formulary |
Senior Whole Health of New York NHC (HMO D-SNP)
![Email Prescription and/or Health Benefit details for Senior Whole Health of New York NHC (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $308.88 |
Browse Plan Formulary |
UnitedHealthcare Assisted Living Plan (PPO I-SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Assisted Living Plan (PPO I-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.40 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $338.85 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Dual Complete Plan 1 (HMO D-SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Dual Complete Plan 1 (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $338.94 |
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)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Dual Complete Plan 1 (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $338.91 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 2 (HMO I-SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Nursing Home Plan 2 (HMO I-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $338.91 |
Browse Plan Formulary |
VNSNY CHOICE EasyCare Plus (HMO D-SNP)
![Email Prescription and/or Health Benefit details for VNSNY CHOICE EasyCare Plus (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $309.15 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO D-SNP)
![Email Prescription and/or Health Benefit details for VNSNY CHOICE Total (HMO D-SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $309.15 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
![Email Prescription and/or Health Benefit details for Empire MediBlue Plus (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$51.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $343.80 |
Browse Plan Formulary |
Empire MediBlue Select (HMO)
![Email Prescription and/or Health Benefit details for Empire MediBlue Select (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$51.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$94.00 | $282.00 | None | $343.80 |
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 |
UnitedHealthcare Medicare Advantage Choice Plan 4 (Regional PPO)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Medicare Advantage Choice Plan 4 (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$51.50 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $338.91 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
EmblemHealth VIP Essential (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Essential (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$55.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $309.72 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Essential (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$55.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $312.27 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Essential (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$55.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $310.80 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Essential (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$55.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $307.20 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
![Email Prescription and/or Health Benefit details for Aetna Medicare Value Plan (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$89.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $342.63 |
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)
![Email Prescription and/or Health Benefit details for Aetna Medicare Premier Plan (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$99.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $342.90 |
Browse Plan Formulary |
Wellcare Premium Ultra Open (PPO)
![Email Prescription and/or Health Benefit details for Wellcare Premium Ultra Open (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$121.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$35.00 | $70.00 | None | $336.42 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Gold (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$124.50 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $309.33 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Gold (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$124.50 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $312.27 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Gold (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$124.50 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $310.80 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Gold (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$124.50 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $307.20 |
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)
![Email Prescription and/or Health Benefit details for EmblemHealth VIP Gold Plus (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$261.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $308.25 |
Browse Plan Formulary |