PROMETHAZINE 50 MG TABLET (100 EA ) (NDC: 10702000401)
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-0007 (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $0.49 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC NY-0019 (PPO)
|
$0.00 |
$195 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $0.49 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Credit Plan (PPO)
|
$0.00 |
$250* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$10.00 | $10.00 | P | $0.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Premier Plan (PPO)
|
$0.00 |
$150* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$0.00 | $0.00 | P | $0.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (HMO-POS)
|
$0.00 |
$150* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$0.00 | $0.00 | P | $0.07 |
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 |
BlueSaver (HMO)
|
$0.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$94.00 | $235.00 | P | $0.12 |
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 | 1* |
Preferred Generic |
$0.00 | $0.00 | P | $0.26 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H3533-006 (HMO)
|
$0.00 |
$350 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $0.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5970-015 (PPO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $0.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5970-018 (PPO)
|
$0.00 |
$310 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $0.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Independent Health's Encompass 65 Edge (HMO)
|
$0.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
41% | 41% | P | $0.17 |
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 |
Independent Health's Encompass 65 Element (HMO)
|
$0.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
49% | 49% | P | $0.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
MVP Medicare Gold Giveback with Part D (PPO)
|
$0.00 |
$400* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$12.00 | $24.00 | None | $0.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Blue Basic (HMO)
|
$0.00 |
$350 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$94.00 | $235.00 | P | $0.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Univera SeniorChoice Basic (HMO)
|
$0.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $0.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Univera SeniorChoice Extra (HMO)
|
$0.00 |
$350 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
21% | 21% | None | $0.14 |
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 | P | $0.09 |
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 Giveback Open (PPO)
|
$0.00 |
$500 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $84.00 | P | $0.42 |
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 | 3 |
Preferred Brand |
$42.00 | $84.00 | P | $0.38 |
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. | 3 |
Preferred Brand |
$42.00 | $84.00 | P | $0.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Independent Health's Medicare Passport Access (PPO)
|
$10.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
48% | 48% | P | $0.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Univera SeniorChoice Access (PPO)
|
$14.40 |
$350 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $0.14 |
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 | 3 |
Preferred Brand |
$47.00 | $94.00 | P | $0.47 |
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 Nursing Home Plan NY-F001 (PPO I-SNP)
|
$23.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $0.49 |
Browse Plan Formulary all covered insulin pay $35 or less |
Freedom Nation (PPO)
|
$24.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$94.00 | $235.00 | P | $0.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
MVP Medicare Secure with Part D (HMO-POS)
|
$25.00 |
$300* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | $30.00 | None | $0.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Nursing Home Plan NY-F004 (HMO-POS I-SNP)
|
$25.60 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $0.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5970-001 (PPO)
|
$27.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$99.00 | $287.00 | None | $0.08 |
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 | 3 |
Preferred Brand |
$47.00 | $94.00 | P | $0.47 |
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 |
Univera SeniorChoice Advanced (HMO-POS)
|
$28.40 |
$100 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $0.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Discover Value Plan (PPO)
|
$29.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | P | $0.07 |
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. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $0.49 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$30.60 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | P | $0.41 |
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 | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $0.51 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Longevity Plan (PPO I-SNP)
|
$38.30 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | P | $0.13 |
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 Assure Plan (HMO D-SNP)
|
$38.60 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | P | $0.13 |
Browse Plan Formulary all covered insulin pay $35 or less |
MVP Medicare Patriot Plan with Part D (PPO)
|
$40.20 |
$250* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | $30.00 | None | $0.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H3533-002 (HMO D-SNP)
|
$40.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | None | $0.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice SNP-DE H5970-020 (PPO D-SNP)
|
$41.30 |
$545 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | None | $0.08 |
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 | 3 |
Tier 3 |
$0.00 | $0.00 | None | $0.51 |
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 | 3 |
Tier 3 |
$0.00 | $0.00 | None | $0.49 |
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 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 | P | $0.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Premium Enhanced (PFFS)
|
$47.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $84.00 | P | $0.40 |
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% | P | $0.21 |
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% | P | $0.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Independent Health's Medicare Family Choice (HMO I-SNP)
|
$48.70 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
25% | 25% | P | $0.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Nascentia Dual Advantage (HMO D-SNP)
|
$48.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $0.22 |
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 |
Nascentia Skilled Nursing Facility (HMO I-SNP)
|
$48.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $0.22 |
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 | 3 |
Tier 3 |
$0.00 | $0.00 | None | $0.51 |
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 | 3 |
Tier 3 |
$0.00 | $0.00 | None | $0.49 |
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 | 3 |
Tier 3 |
$0.00 | $0.00 | None | $0.51 |
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 | 3 |
Tier 3 |
$0.00 | $0.00 | None | $0.49 |
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 | P | $0.40 |
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 |
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 | P | $0.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Blue Select (HMO)
|
$52.00 |
$175 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$94.00 | $235.00 | P | $0.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Univera SeniorChoice Value Plus (HMO-POS)
|
$55.40 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $0.14 |
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. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $0.49 |
Browse Plan Formulary all covered insulin pay $35 or less |
Independent Health's Assure Advantage (HMO C-SNP)
|
$60.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
38% | 38% | P | $0.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Independent Health's Encompass 65 Core (HMO)
|
$65.00 |
$50 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | P | $0.17 |
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 |
Univera SeniorChoice Secure (HMO-POS)
|
$70.40 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $0.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
MVP Medicare WellSelect Plus with Part D (PPO)
|
$85.90 |
$250* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $20.00 | None | $0.04 |
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. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $0.49 |
Browse Plan Formulary all covered insulin pay $35 or less |
Independent Health's Medicare Passport Advantage (PPO)
|
$104.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
43% | 43% | P | $0.17 |
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 | 3 |
Preferred Brand |
$42.00 | $84.00 | P | $0.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Blue 651 (HMO)
|
$115.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$94.00 | $235.00 | P | $0.12 |
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 |
Independent Health's Encompass 65 Basic (HMO)
|
$129.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
49% | 49% | P | $0.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Premium Ultra (PFFS)
|
$136.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $84.00 | P | $0.40 |
Browse Plan Formulary all covered insulin pay $35 or less |
Forever Blue Value (PPO)
|
$144.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$94.00 | $235.00 | P | $0.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plan (PPO)
|
$150.00 |
$250* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$10.00 | $10.00 | P | $0.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
Forever Blue 751 (PPO)
|
$209.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$94.00 | $235.00 | P | $0.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
MVP Medicare Preferred Gold with Part D (HMO-POS)
|
$222.40 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $20.00 | None | $0.04 |
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 |
Independent Health's Medicare Passport Prime (PPO)
|
$235.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
50% | 50% | P | $0.17 |
Browse Plan Formulary all covered insulin pay $35 or less |