ROFLUMILAST 250 MCG TABLET [Daliresp] (30 TABLETS ) (NDC: 72205020132)
2024 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. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $253.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $235.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Select Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $243.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
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:28 /28Days | $167.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $90.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 Flex (HMO-POS)
|
$0.00 |
$375* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $94.00 | Q:56 /365Days | $116.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
Elderplan Select (HMO-POS I-SNP)
|
$0.00 |
$545* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $94.00 | Q:56 /365Days | $116.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$35.00 | $35.00 | Q:56 /365Days | $155.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
Healthfirst Signature (HMO)
|
$0.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $47.00 | Q:56 /365Days | $155.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
Healthfirst Signature (PPO)
|
$0.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $47.00 | Q:56 /365Days | $156.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
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:28 /365Days | $108.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
|
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 |
$425* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:28 /365Days | $113.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5970-024 (PPO)
|
$0.00 |
$425* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $131.00 | Q:28 /365Days | $97.77 |
Browse Plan Formulary all covered insulin pay $35 or less |
PHP Care Complete FIDA-IDD Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Tier 1 |
0% | 0% | Q:28 /28Days | $117.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Fidelis No Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $0.00 | None | $77.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback Open (PPO)
|
$0.00 |
$500 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $79.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
|
$0.00 |
$425 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
47% | 47% | None | $81.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 Open (PPO)
|
$0.00 |
$450 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $79.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist Open (PPO)
|
$20.60 |
$510 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
46% | 46% | None | $79.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Nursing Home Plan NY-F003 (HMO I-SNP)
|
$22.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | P Q:28 /28Days | $107.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Discover Value Plan (PPO)
|
$24.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $178.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Dual (HMO D-SNP)
|
$24.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $128.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Dual (HMO D-SNP)
|
$24.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $128.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
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)
|
$24.80 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $128.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
VNS Health EasyCare (HMO)
|
$25.00 |
$145 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $60.00 | Q:28 /28Days | $117.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Whole Health of New York NHC (HMO D-SNP)
|
$25.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:56 /365Days | $78.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Nursing Home Plan NY-F002 (PPO I-SNP)
|
$26.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | P Q:28 /28Days | $106.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Whole Health Medicare Complete Care (HMO D-SNP)
|
$26.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:56 /365Days | $78.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Whole Health Medicare Complete Care (HMO D-SNP)
|
$26.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:56 /365Days | $78.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 |
Longevity Health Plan (HMO I-SNP)
|
$26.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | P Q:30 /30Days | $128.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Fidelis Assist (HMO-POS)
|
$27.50 |
$430 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $78.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H3533-032 (HMO)
|
$29.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:28 /365Days | $113.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H3533-032 (HMO)
|
$29.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:28 /365Days | $143.61 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Medicare Advantage NY-0020 (Regional PPO)
|
$29.00 |
$295 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:28 /28Days | $105.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Plus Medicare (PPO)
|
$32.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $90.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
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)
|
$32.30 |
$540 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $90.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Elderplan For Medicaid Beneficiaries (HMO-POS D-SNP)
|
$33.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:56 /365Days | $116.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
Elderplan Assist (HMO-POS I-SNP)
|
$34.50 |
$545* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $94.00 | Q:56 /365Days | $116.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
Elderplan Extra Help (HMO-POS)
|
$34.70 |
$545* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$47.00 | $94.00 | Q:56 /365Days | $116.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Care Advantage NY-E001 (PPO I-SNP)
|
$35.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:28 /28Days | $106.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$35.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $88.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
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)
|
$39.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:56 /365Days | $157.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
Hamaspik Medicare Choice (HMO D-SNP)
|
$42.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P Q:30 /30Days | $171.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Hamaspik Medicare Select (HMO D-SNP)
|
$42.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P Q:30 /30Days | $180.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete NY-Q001 (HMO-POS D-SNP)
|
$42.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | P Q:28 /28Days | $104.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete NY-Q001 (HMO-POS D-SNP)
|
$42.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | P Q:28 /28Days | $106.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC NY-0005 (HMO-POS)
|
$43.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:28 /28Days | $105.56 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 Life Improvement Plan (HMO D-SNP)
|
$43.30 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
16% | 16% | Q:56 /365Days | $156.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Fidelis Dual Access (HMO D-SNP)
|
$44.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $80.35 |
Browse Plan Formulary all covered insulin pay $35 or less |
Healthfirst CompleteCare (HMO D-SNP)
|
$45.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
19% | 19% | Q:56 /365Days | $156.83 |
Browse Plan Formulary all covered insulin pay $35 or less |
Elderplan Advantage For Nursing Home Residents (HMO-POS I-SNP)
|
$48.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:56 /365Days | $116.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
Healthfirst Connection Plan (HMO D-SNP)
|
$48.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:56 /365Days | $157.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Assure Plan (HMO D-SNP)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $173.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 |
Anthem Full Dual Advantage (HMO D-SNP)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | P Q:30 /30Days | $69.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Full Dual Advantage Select (HMO D-SNP)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | P Q:30 /30Days | $69.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem HealthPlus Full Dual Advantage (HMO D-SNP)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | P Q:30 /30Days | $69.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem HealthPlus Full Dual Advantage LTSS (HMO D-SNP)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | P Q:30 /30Days | $69.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Centers Plan for Dual Coverage Care (HMO D-SNP)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:28 /28Days | $165.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
Centers Plan for Medicaid Advantage Plus (HMO D-SNP)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:28 /28Days | $169.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
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)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:28 /28Days | $169.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
Elderplan Plus Long Term Care (HMO-POS D-SNP)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:56 /365Days | $116.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H3533-034 (HMO D-SNP)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:28 /365Days | $114.35 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H3533-034 (HMO D-SNP)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:28 /365Days | $104.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice SNP-DE H5970-026 (PPO D-SNP)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$0.00 | $0.00 | Q:28 /365Days | $112.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
MetroPlus Advantage Plan (HMO D-SNP)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:56 /365Days | $83.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 UltraCare (HMO D-SNP)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:56 /365Days | $83.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
RiverSpring MAP (HMO D-SNP)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P Q:30 /30Days | $128.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
RiverSpring Star (HMO I-SNP)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | P Q:30 /30Days | $128.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete NY-S001 (PPO D-SNP)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | P Q:28 /28Days | $104.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete NY-S001 (PPO D-SNP)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | P Q:28 /28Days | $106.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete NY-S002 (HMO-POS D-SNP)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | P Q:28 /28Days | $104.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 |
UHC Dual Complete NY-S002 (HMO-POS D-SNP)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | P Q:28 /28Days | $106.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
VillageCareMAX Medicare Health Advantage FLEX Plan (HMO D-SNP)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | Q:28 /28Days | $117.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
VillageCareMAX Medicare Health Advantage Plan (HMO D-SNP)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | Q:28 /28Days | $117.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
VillageCareMAX Medicare Select Advantage Plan (HMO)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | Q:28 /28Days | $117.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
VillageCareMAX Medicare Total Advantage Plan (HMO D-SNP)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$12.00 | $36.00 | Q:28 /28Days | $117.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
VNS Health EasyCare Plus (HMO D-SNP)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:28 /28Days | $117.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 |
VNS Health Total (HMO D-SNP)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:28 /28Days | $117.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $80.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Fidelis Dual Plus (HMO D-SNP)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $86.06 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plan (PPO)
|
$49.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $251.63 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Medicare Advantage NY-0021 (Regional PPO)
|
$56.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:28 /28Days | $105.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC NY-0001 (HMO-POS)
|
$62.00 |
$295 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:28 /28Days | $105.56 |
Browse Plan Formulary all covered insulin pay $35 or less |
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)
|
$82.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:30 /30Days | $128.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Gold (HMO)
|
$82.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:30 /30Days | $128.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Gold (HMO)
|
$82.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:30 /30Days | $128.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Medicare Advantage NY-0022 (Regional PPO)
|
$88.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:28 /28Days | $105.62 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Premium Ultra Open (PPO)
|
$110.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $79.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
MetroPlus Platinum Plan (HMO)
|
$132.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:56 /365Days | $83.57 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 Platinum Plan (PPO)
|
$171.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $179.71 |
Browse Plan Formulary all covered insulin pay $35 or less |
EmblemHealth VIP Gold Plus (HMO)
|
$241.00 |
$200 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:30 /30Days | $128.70 |
Browse Plan Formulary all covered insulin pay $35 or less |