TRULICITY 1.5 MG/0.5 ML PEN (.5 ML ) (NDC: 00002143480)
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 | Q:2 /28Days | $957.30 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $957.48 |
Browse Plan Formulary |
Centers Plan for Medicare Advantage Care (HMO)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $117.50 | Q:2 /28Days | $895.62 |
Browse Plan Formulary |
EmblemHealth VIP Value (HMO)
|
$0.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:2 /28Days | $890.20 |
Browse Plan Formulary |
Empire MediBlue HealthPlus (HMO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:2 /28Days | $961.26 |
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 Select (HMO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:2 /28Days | $961.26 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$295 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $47.00 | Q:2 /28Days | $936.02 |
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 |
3 |
Preferred Brand |
$47.00 | $47.00 | Q:2 /28Days | $936.02 |
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 |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $956.02 |
Browse Plan Formulary |
HumanaChoice H5970-024 (PPO)
|
$0.00 |
$350* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $966.02 |
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 |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $951.98 |
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% | Q:2 /28Days | $860.66 |
Browse Plan Formulary |
Wellcare Fidelis No Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$37.00 | $74.00 | Q:2 /28Days | $939.64 |
Browse Plan Formulary |
Wellcare Giveback Open (PPO)
|
$0.00 |
$325 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $74.00 | Q:2 /28Days | $939.44 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$37.00 | $74.00 | Q:2 /28Days | $940.18 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $74.00 | Q:2 /28Days | $939.44 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO)
|
$16.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $945.22 |
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 |
Wellcare Fidelis Assist (HMO-POS)
|
$17.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
22% | 22% | Q:2 /28Days | $936.64 |
Browse Plan Formulary |
Wellcare Fidelis Dual Plus (HMO D-SNP)
|
$18.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:2 /28Days | $936.52 |
Browse Plan Formulary |
Wellcare Assist (HMO)
|
$19.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:2 /28Days | $936.64 |
Browse Plan Formulary |
Wellcare Fidelis Dual Access (HMO D-SNP)
|
$20.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:2 /28Days | $936.54 |
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 | Q:2 /28Days | $957.30 |
Browse Plan Formulary |
Aetna Medicare Elite Plan 3 (PPO)
|
$25.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $957.48 |
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 |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $863.04 |
Browse Plan Formulary |
Humana Gold Plus H3533-032 (HMO)
|
$27.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $965.66 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H3533-032 (HMO)
|
$27.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $951.98 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Dual Access (HMO D-SNP)
|
$27.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:2 /28Days | $936.52 |
Browse Plan Formulary |
Wellcare Assist Open (PPO)
|
$30.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:2 /28Days | $936.50 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 2 (HMO)
|
$34.00 |
$395 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $945.98 |
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 |
UnitedHealthcare Medicare Advantage Choice Plan 3 (Regional PPO)
|
$34.20 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $945.22 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Empire MediBlue Extra Select (HMO)
|
$36.60 |
$480 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $961.26 |
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:2 /28Days | $875.36 |
Browse Plan Formulary |
Wellcare Dual Access Open (PPO D-SNP)
|
$37.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:2 /28Days | $936.54 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Plan 2 (HMO D-SNP)
|
$37.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:2 /28Days | $945.44 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Plan 2 (HMO D-SNP)
|
$37.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:2 /28Days | $944.96 |
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 SNP-DE H3533-034 (HMO D-SNP)
|
$38.90 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $960.54 |
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 |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $952.22 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO D-SNP)
|
$39.90 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $936.04 |
Browse Plan Formulary |
Elderplan Assist (HMO I-SNP)
|
$42.00 |
$480* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $94.00 | Q:2 /28Days | $862.38 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)
|
$42.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:2 /28Days | $945.50 |
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% | Q:2 /28Days | $862.36 |
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 Dual Coverage Care (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:2 /28Days | $893.78 |
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:2 /28Days | $893.82 |
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:2 /28Days | $895.76 |
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% | Q:2 /28Days | $862.38 |
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% | Q:2 /28Days | $862.36 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:2 /28Days | $895.96 |
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 |
3 |
Tier 3 |
$0.00 | $0.00 | Q:2 /28Days | $897.42 |
Browse Plan Formulary |
EmblemHealth VIP Dual (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:2 /28Days | $882.96 |
Browse Plan Formulary |
EmblemHealth VIP Solutions (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | Q:2 /28Days | $888.94 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage (HMO D-SNP)
|
$42.40 |
$480 |
Some Generics |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $960.42 |
Browse Plan Formulary |
Empire MediBlue Dual Advantage Select (HMO D-SNP)
|
$42.40 |
$480 |
Some Generics |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $960.38 |
Browse Plan Formulary |
Empire MediBlue HealthPlus Dual Connect (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $960.04 |
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)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $960.04 |
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:2 /28Days | $867.18 |
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:2 /28Days | $867.22 |
Browse Plan Formulary |
Healthfirst Connection Plan (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $936.04 |
Browse Plan Formulary |
Healthfirst Increased Benefits Plan (HMO)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $936.04 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $936.04 |
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 Advantage Plan (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:2 /28Days | $840.96 |
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 | Q:2 /28Days | $840.96 |
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% | Q:2 /28Days | $869.06 |
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% | Q:2 /28Days | $869.06 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Plan 1 (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:2 /28Days | $945.44 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Plan 1 (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:2 /28Days | $944.96 |
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 Nursing Home Plan 2 (HMO I-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:2 /28Days | $945.46 |
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:2 /28Days | $863.04 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO D-SNP)
|
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $863.04 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Choice Plan 4 (Regional PPO)
|
$51.50 |
$150 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $945.22 |
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. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:2 /28Days | $945.98 |
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 |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:2 /28Days | $897.04 |
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)
|
$55.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:2 /28Days | $896.94 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$55.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:2 /28Days | $882.92 |
Browse Plan Formulary |
EmblemHealth VIP Essential (HMO)
|
$55.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:2 /28Days | $891.28 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$99.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:2 /28Days | $957.20 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$124.50 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:2 /28Days | $891.48 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$124.50 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:2 /28Days | $897.04 |
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)
|
$124.50 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:2 /28Days | $896.94 |
Browse Plan Formulary |
EmblemHealth VIP Gold (HMO)
|
$124.50 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:2 /28Days | $882.92 |
Browse Plan Formulary |
MetroPlus Platinum Plan (HMO)
|
$149.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:2 /28Days | $840.96 |
Browse Plan Formulary |
EmblemHealth VIP Gold Plus (HMO)
|
$261.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:2 /28Days | $887.30 |
Browse Plan Formulary |