AARP Medicare Advantage Mosaic Choice (PPO) - H3418-001-0
Benefit Details
|
Queens |
$0.00 |
$250 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin pay $35 copay | $6,900 Browse Formulary |
|
|
|
|
AARP Medicare Advantage Patriot (HMO) - H3307-018-0
Benefit Details
|
Queens |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $6,700 |
|
|
|
|
AARP Medicare Advantage Prime (HMO) - H3307-015-0
Benefit Details
|
Queens |
$0.00 |
$295 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Aetna Medicare Eagle Plan (PPO) - H5521-320-0
Benefit Details
|
Queens |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $7,550 |
|
|
|
|
Aetna Medicare Elite Plan (PPO) - H5521-120-0
Benefit Details
|
Queens |
$0.00 |
$300 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Bright Advantage Classic Care Plan (HMO) - H2288-001-0
Benefit Details
|
Queens |
$0.00 |
$250 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,200 Browse Formulary |
|
-- |
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Bright Advantage Embrace Care Plan (HMO C-SNP) - H2288-009-0
Benefit Details
|
Queens |
$0.00 |
$0 |
Some Generics | Preferred Generic: $0.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $90.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $0-$35 copay | n/a Browse Formulary |
|
-- |
|
|
Centers Plan for Medicare Advantage Care (HMO) - H6988-001-0
Benefit Details
|
Queens |
$0.00 |
$395 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
|
-- |
|
|
EmblemHealth VIP Essential (HMO) - H3330-032-1
Benefit Details
|
Queens |
$0.00 |
$325 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 27%
| $7,550 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
EmblemHealth VIP Reserve (HMO) - H5991-009-0
Benefit Details
|
Queens |
$0.00 |
$325 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 27%
| $7,550 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
EmblemHealth VIP Value (HMO) - H3330-036-0
Benefit Details
|
Queens |
$0.00 |
$325 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 27%
| $7,550 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Empire MediBlue HealthPlus (HMO) - H1732-004-0
Benefit Details
|
Queens |
$0.00 |
$350 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: $94.00 Specialty Tier: 27% Select Care Drugs: $0.00
| $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Empire MediBlue HealthPlus Select (HMO) - H1732-007-0
Benefit Details
|
Queens |
$0.00 |
$350 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $35.00 Non-Preferred Drug: $94.00 Specialty Tier: 27% Select Care Drugs: $0.00
select insulin pay $35 copay | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Empire MediBlue Select (HMO) - H8432-027-0
Benefit Details
|
Queens |
$0.00 |
$350 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: $94.00 Specialty Tier: 27% Select Care Drugs: $0.00
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Empire MediBlue Service (HMO) - H8432-037-1
Benefit Details
|
Queens |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $7,550 |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Empire MediBlue Service Select (HMO) - H8432-036-0
Benefit Details
|
Queens |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $6,700 |
|
|
|
|
Healthfirst 65 Plus Plan (HMO) - H3359-001-0
Benefit Details
|
Queens |
$0.00 |
$295 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26% Supplemental Drugs: $10.00
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
|
Healthfirst Coordinated Benefits Plan (HMO) - H3359-027-0
Benefit Details
|
Queens |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $7,550 |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Healthfirst Signature (HMO) - H5989-011-0
Benefit Details
|
Queens |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26% Supplemental Drugs: $10.00
select insulin pay $35 copay | $7,550 Browse Formulary |
|
-- |
-- |
|
Humana Gold Plus H3533-027 (HMO) - H3533-027-0
Benefit Details
|
Queens |
$0.00 |
$425 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Humana Gold Plus H3533-033 (HMO) - H3533-033-0
Benefit Details
|
Queens |
$0.00 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Humana Honor (PPO) - H5970-016-0
Benefit Details
|
Queens |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,500 |
|
|
|
|
HumanaChoice H5970-024 (PPO) - H5970-024-1
Benefit Details
|
Queens |
$0.00 |
$350 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
select insulin pay $35 copay | $7,200 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PHP Care Complete FIDA-IDD Plan (Medicare-Medicaid Plan) - H9869-001-0
Benefit Details
|
Queens |
$0.00 |
$0 |
All Generics, All Brands | Tier 1: 0%
| n/a Browse Formulary |
-- |
-- |
-- |
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare Medicare Advantage Patriot (Regional PPO) - R5342-002-0
Benefit Details
|
Queens |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $6,700 |
|
|
|
|
Wellcare Giveback Open (PPO) - H2775-111-0
Benefit Details
|
Queens |
$0.00 |
$325 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 48% Specialty Tier: 27% Select Care Drugs: $0.00
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare No Premium (HMO) - H4868-019-0
Benefit Details
|
Queens |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 48% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare No Premium Open (PPO) - H2775-106-0
Benefit Details
|
Queens |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 42% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Empire MediBlue Plus (HMO) - H8432-008-6
Benefit Details
|
Queens |
$16.00 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: $94.00 Specialty Tier: 27%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO) - R5342-001-0
Benefit Details
|
Queens |
$16.00 |
$300 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | $7,200 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Fidelis Dual Plus (HMO D-SNP) - H5599-003-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: 33% Specialty Tier: 25% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
|
Wellcare Assist (HMO) - H4868-016-0
Benefit Details
|
Queens |
$19.40 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
-- |
|
|
Wellcare Fidelis Dual Access (HMO D-SNP) - H5599-001-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: 33% Specialty Tier: 25% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Aetna Medicare Assure Plan (HMO D-SNP) - H3312-069-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $47.00 Non-Preferred Drug: 25% Specialty Tier: 26%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Humana Gold Plus H3533-032 (HMO) - H3533-032-1
Benefit Details
|
Queens |
$24.00 |
$200 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
select insulin pay $35 copay | $6,500 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare Elite Plan 3 (PPO) - H5521-310-0
Benefit Details
|
Queens |
$25.00 |
$300 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
VNSNY CHOICE EasyCare (HMO) - H5549-012-0
Benefit Details
|
Queens |
$25.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $15.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $7,550 Browse Formulary |
|
|
|
|
Aetna Medicare Discover Value Plan (PPO) - H5521-312-0
Benefit Details
|
Queens |
$26.00 |
$300 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Dual Access (HMO D-SNP) - H4868-014-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: 42% Specialty Tier: 25% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Assist Open (PPO) - H2775-113-0
Benefit Details
|
Queens |
$30.70 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $45.00 Non-Preferred Drug: 44% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
|
AARP Medicare Advantage Plan 2 (HMO) - H3379-001-0
Benefit Details
|
Queens |
$34.00 |
$395 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
|
EmblemHealth VIP Passport NYC (HMO) - H5991-006-0
Benefit Details
|
Queens |
$34.90 |
$350 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 27%
| $7,550 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Empire MediBlue Extra Select (HMO) - H8432-035-0
Benefit Details
|
Queens |
$36.60 |
$480 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Longevity Health Plan (HMO I-SNP) - H8457-001-0
Benefit Details
|
Queens |
$36.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 25%
| n/a Browse Formulary |
|
-- |
|
|
Wellcare Dual Access Open (PPO D-SNP) - H2775-112-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: 49% Specialty Tier: 25% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare Dual Complete Plan 2 (HMO D-SNP) - H3387-015-2
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00
| n/a Browse Formulary |
|
|
|
|
Humana Gold Plus SNP-DE H3533-034 (HMO D-SNP) - H3533-034-1
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare Elite Plan (HMO) - H3312-068-0
Benefit Details
|
Queens |
$39.00 |
$300 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Elderplan For Medicaid Beneficiaries (HMO D-SNP) - H3347-002-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 15%
| n/a Browse Formulary |
|
|
|
|
Healthfirst CompleteCare (HMO D-SNP) - H3359-034-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: 25% Specialty Tier: 25%
| n/a Browse Formulary |
|
|
|
|
Bright Advantage Embrace Choice Plan (HMO C-SNP) - H2288-010-0
Benefit Details
|
Queens |
$41.60 |
$480 Tier 1 and 6 exempt |
Some Generics | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Elderplan Assist (HMO I-SNP) - H3347-015-0
Benefit Details
|
Queens |
$42.00 |
$480 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: 25% Specialty Tier: 25%
| n/a Browse Formulary |
|
|
|
|
Elderplan Extra Help (HMO) - H3347-009-0
Benefit Details
|
Queens |
$42.00 |
$480 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
|
|
|
|
UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP) - H2292-002-0
Benefit Details
|
Queens |
$42.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 25%
| n/a Browse Formulary |
|
-- |
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
AgeWell New York Advantage Plus (HMO D-SNP) - H4922-010-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00
| n/a Browse Formulary |
|
-- |
|
|
AgeWell New York CareWell (HMO I-SNP) - H4922-004-0
Benefit Details
|
Queens |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 25%
| n/a Browse Formulary |
|
-- |
|
|
AgeWell New York FeelWell (HMO D-SNP) - H4922-003-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00
| n/a Browse Formulary |
|
-- |
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
AgeWell New York LiveWell (HMO) - H4922-011-0
Benefit Details
|
Queens |
$42.40 |
$350 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $7,550 Browse Formulary |
|
-- |
|
|
ArchCare Advantage (HMO I-SNP) - H1777-007-0
Benefit Details
|
Queens |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 25%
| n/a Browse Formulary |
|
-- |
|
|
Bright Advantage Dual Access Plan (HMO D-SNP) - H2288-003-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
Some Generics | Preferred Generic: $0.00 Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Centers Plan for Dual Coverage Care (HMO D-SNP) - H6988-002-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 15%
| n/a Browse Formulary |
|
-- |
|
|
Centers Plan for Medicaid Advantage Plus (HMO D-SNP) - H6988-004-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00
| n/a Browse Formulary |
|
-- |
|
|
Centers Plan for Nursing Home Care (HMO I-SNP) - H6988-003-0
Benefit Details
|
Queens |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 25%
| n/a Browse Formulary |
|
-- |
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Elderplan Advantage For Nursing Home Residents (HMO I-SNP) - H3347-003-0
Benefit Details
|
Queens |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 25%
| n/a Browse Formulary |
|
|
|
|
Elderplan Plus Long Term Care (HMO D-SNP) - H3347-007-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 15%
| n/a Browse Formulary |
|
|
|
|
EmblemHealth VIP Assist (HMO D-SNP) - H5991-008-0
Sanctioned Plan
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: tbd
| n/a Browse Formulary |
|
-- |
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
EmblemHealth VIP Dual (HMO D-SNP) - H3330-042-1
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00
| n/a Browse Formulary |
|
-- |
|
|
EmblemHealth VIP Dual Reserve (HMO D-SNP) - H5991-010-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00
| n/a Browse Formulary |
|
-- |
|
|
EmblemHealth VIP Dual Select (HMO D-SNP) - H5991-001-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00
| n/a Browse Formulary |
|
-- |
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
EmblemHealth VIP Solutions (HMO D-SNP) - H5991-002-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 15%
| n/a Browse Formulary |
|
-- |
|
|
Empire MediBlue Dual Advantage (HMO D-SNP) - H8432-007-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
Some Generics | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Empire MediBlue Dual Advantage Select (HMO D-SNP) - H8432-028-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
Some Generics | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Empire MediBlue HealthPlus Dual Connect (HMO D-SNP) - H1732-003-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $10.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $10.00
| n/a Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Empire MediBlue HealthPlus Dual Plus (HMO D-SNP) - H1732-001-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $10.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $10.00
| n/a Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Hamaspik Medicare Choice (HMO D-SNP) - H0034-002-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 15%
| n/a Browse Formulary |
|
new |
new |
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Hamaspik Medicare Select (HMO D-SNP) - H0034-001-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 15%
| n/a Browse Formulary |
|
new |
new |
|
Healthfirst Connection Plan (HMO D-SNP) - H3359-038-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| n/a Browse Formulary |
|
|
|
|
Healthfirst Increased Benefits Plan (HMO) - H3359-019-0
Benefit Details
|
Queens |
$42.40 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25% Supplemental Drugs: $20.00
| $7,550 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Healthfirst Life Improvement Plan (HMO D-SNP) - H3359-021-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: 42% Specialty Tier: 25%
| n/a Browse Formulary |
|
|
|
|
Integra Harmony (HMO D-SNP) - H1205-001-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 15%
| n/a Browse Formulary |
|
-- |
-- |
|
Integra Synergy Medicaid Advantage Plus (MAP) (HMO D-SNP) - H1205-002-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00
| n/a Browse Formulary |
|
-- |
-- |
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
MetroPlus Advantage Plan (HMO D-SNP) - H0423-001-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 15%
| n/a Browse Formulary |
|
|
|
|
MetroPlus UltraCare (HMO D-SNP) - H0423-007-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00
| n/a Browse Formulary |
|
|
|
|
RiverSpring MAP (HMO D-SNP) - H6776-002-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 15%
| n/a Browse Formulary |
|
-- |
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
RiverSpring Star (HMO I-SNP) - H6776-001-0
Benefit Details
|
Queens |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 25%
| n/a Browse Formulary |
|
-- |
|
|
Senior Whole Health Medicare Complete Care (HMO D-SNP) - H5992-008-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00
| n/a Browse Formulary |
|
-- |
|
|
Senior Whole Health of New York NHC (HMO D-SNP) - H5992-007-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00
| n/a Browse Formulary |
|
-- |
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare Assisted Living Plan (PPO I-SNP) - H2292-003-0
Benefit Details
|
Queens |
$42.40 |
$200 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
select insulin pay $35 copay | n/a Browse Formulary |
|
-- |
|
|
UnitedHealthcare Dual Complete Plan 1 (HMO D-SNP) - H3387-014-2
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Nursing Home Plan 2 (HMO I-SNP) - H3379-002-0
Benefit Details
|
Queens |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 25%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
VillageCareMAX Medicare Health Advantage (HMO D-SNP) - H2168-001-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 15%
| n/a Browse Formulary |
|
-- |
|
|
VNSNY CHOICE EasyCare Plus (HMO D-SNP) - H5549-011-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 15%
| n/a Browse Formulary |
|
|
|
|
VNSNY CHOICE Total (HMO D-SNP) - H5549-003-0
Benefit Details
|
Queens |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $13.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare Medicare Advantage Choice Plan 3 (Regional PPO) - R5342-005-0
Benefit Details
|
Queens |
$46.00 |
$250 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | $6,900 Browse Formulary |
|
|
|
|
AARP Medicare Advantage Plan 1 (HMO) - H3307-002-0
Benefit Details
|
Queens |
$54.00 |
$395 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
|
Bright Advantage Classic Plus Plan (HMO) - H2288-002-0
Benefit Details
|
Queens |
$59.00 |
$480 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $4,900 Browse Formulary |
|
-- |
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare Medicare Advantage Choice Plan 4 (Regional PPO) - R5342-006-0
Benefit Details
|
Queens |
$84.00 |
$150 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
select insulin coverage $35 or less | $6,700 Browse Formulary |
|
|
|
|
EmblemHealth VIP Gold (HMO) - H3330-021-1
Benefit Details
|
Queens |
$97.00 |
$200 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare Premier Plan (PPO) - H5521-040-0
Benefit Details
|
Queens |
$99.00 |
$250 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
VillageCareMAX Medicare Total Advantage (HMO D-SNP) - H2168-002-0
Benefit Details
|
Queens |
$74.60 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00
| n/a Browse Formulary |
|
-- |
|
|
Wellcare Premium Ultra Open (PPO) - H2775-105-0
Benefit Details
|
Queens |
$121.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MetroPlus Platinum Plan (HMO) - H0423-004-0
Benefit Details
|
Queens |
$149.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 25%
| $7,550 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
EmblemHealth VIP Gold Plus (HMO) - H3330-038-0
Benefit Details
|
Queens |
$261.00 |
$200 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|