SUMATRIPTAN 6 MG/0.5 ML PEN INJECTOR [Sumavel DosePro System] (1 ML ) (NDC: 66993008498)
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 |
AARP Medicare Advantage from UHC NY-0003 (HMO-POS)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:6 /30Days | $54.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC NY-0012 (PPO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:6 /30Days | $54.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC NY-0028 (HMO-POS)
|
$0.00 |
$395 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:6 /30Days | $54.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite Plan (PPO)
|
$0.00 |
$300 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:4 /30Days | $25.11 |
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 | Q:4 /30Days | $34.21 |
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 Value Select Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:4 /30Days | $29.04 |
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:4 /28Days | $94.69 |
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 | Q:8 /28Days | $104.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Elderplan Flex (HMO-POS)
|
$0.00 |
$375 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:6 /30Days | $41.80 |
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 |
4 |
Non-Preferred Drug |
25% | 25% | Q:6 /30Days | $42.16 |
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 |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:6 /30Days | $96.62 |
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 Signature (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:6 /30Days | $96.62 |
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 |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:6 /30Days | $96.62 |
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 |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:6 /30Days | $73.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H3533-033 (HMO)
|
$0.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:6 /30Days | $79.10 |
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 |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:6 /30Days | $78.05 |
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 |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:6 /30Days | $69.94 |
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 |
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:4 /28Days | $75.99 |
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% | Q:6 /30Days | $125.48 |
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% | Q:6 /30Days | $124.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$450 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:6 /30Days | $125.48 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Medicare Advantage (HMO)
|
$16.00 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$94.00 | $282.00 | Q:6 /30Days | $139.52 |
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% | Q:6 /30Days | $107.34 |
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 Elite Plan 3 (PPO)
|
$22.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
40% | 40% | Q:4 /30Days | $32.17 |
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% | Q:6 /30Days | $47.52 |
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 | Q:8 /28Days | $76.59 |
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 | Q:8 /28Days | $76.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 | Q:8 /28Days | $76.59 |
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:4 /28Days | $75.99 |
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 |
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:6 /30Days | $89.41 |
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% | Q:6 /30Days | $42.59 |
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:6 /30Days | $89.41 |
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:6 /30Days | $89.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
Longevity Health Plan (HMO I-SNP)
|
$26.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | Q:8 /28Days | $76.59 |
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 |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:6 /30Days | $78.05 |
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 |
Humana Gold Plus H3533-032 (HMO)
|
$29.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:6 /30Days | $71.56 |
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 | Q:6 /30Days | $43.18 |
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 | Q:8 /28Days | $104.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist (HMO)
|
$32.30 |
$540 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | Q:6 /30Days | $96.13 |
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:6 /30Days | $41.32 |
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 |
4 |
Non-Preferred Drug |
25% | 25% | Q:6 /30Days | $42.16 |
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 Extra Help (HMO-POS)
|
$34.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:6 /30Days | $41.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Discover Value Plan (PPO)
|
$35.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:4 /30Days | $33.52 |
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 | Q:6 /30Days | $44.29 |
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 | Q:6 /30Days | $62.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Healthfirst Increased Benefits Plan (HMO)
|
$39.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:6 /30Days | $96.62 |
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% | Q:6 /30Days | $135.40 |
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 |
Hamaspik Medicare Select (HMO D-SNP)
|
$42.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | Q:6 /30Days | $138.05 |
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 | Q:6 /30Days | $42.16 |
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 | Q:6 /30Days | $45.66 |
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 | Q:6 /30Days | $53.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
Healthfirst Life Improvement Plan (HMO D-SNP)
|
$43.30 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:6 /30Days | $96.62 |
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 | Q:6 /30Days | $43.21 |
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 CompleteCare (HMO D-SNP)
|
$45.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:6 /30Days | $96.62 |
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:6 /30Days | $42.16 |
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 |
4 |
Non-Preferred Drug |
44% | 44% | Q:6 /30Days | $96.62 |
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 | Q:4 /30Days | $36.05 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 | Q:6 /30Days | $101.23 |
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 | Q:6 /30Days | $101.21 |
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 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 | Q:6 /30Days | $101.17 |
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 | Q:6 /30Days | $101.17 |
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:4 /28Days | $90.54 |
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:4 /28Days | $93.79 |
Browse Plan Formulary all covered insulin pay $35 or less |
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:4 /28Days | $93.79 |
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:6 /30Days | $41.54 |
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 |
Humana Gold Plus SNP-DE H3533-034 (HMO D-SNP)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:6 /30Days | $77.80 |
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 |
4 |
Tier 4 |
$0.00 | $0.00 | Q:6 /30Days | $70.54 |
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:6 /30Days | $74.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
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:6 /30Days | $74.97 |
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% | Q:8 /28Days | $103.41 |
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% | Q:8 /28Days | $103.41 |
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-S001 (PPO D-SNP)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | Q:6 /30Days | $42.16 |
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 | Q:6 /30Days | $45.66 |
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 | Q:6 /30Days | $42.16 |
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 | Q:6 /30Days | $45.66 |
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 |
4 |
Non-Preferred Drug |
40% | 40% | Q:4 /28Days | $75.99 |
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 |
4 |
Non-Preferred Drug |
37% | 37% | Q:4 /28Days | $75.99 |
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 |
VillageCareMAX Medicare Select Advantage Plan (HMO)
|
$48.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
33% | 33% | Q:4 /28Days | $75.99 |
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 |
4 |
Non-Preferred Drug |
33% | 33% | Q:4 /28Days | $75.99 |
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:4 /28Days | $75.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
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:4 /28Days | $75.99 |
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 | Q:6 /30Days | $41.53 |
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 | Q:6 /30Days | $52.33 |
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 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 | Q:6 /30Days | $43.18 |
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 | Q:6 /30Days | $53.88 |
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 | Q:8 /28Days | $76.59 |
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 | Q:8 /28Days | $76.59 |
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 | Q:8 /28Days | $76.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plan (PPO)
|
$87.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:4 /30Days | $29.61 |
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 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 | Q:6 /30Days | $43.18 |
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% | Q:6 /30Days | $125.48 |
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:6 /30Days | $74.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plan (PPO)
|
$171.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:4 /30Days | $38.06 |
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 | Q:8 /28Days | $76.59 |
Browse Plan Formulary all covered insulin pay $35 or less |