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UPDATED: Oct 29, 2021

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The Highlights

  • Options for Medicare Supplement in Tupper Lake, New York include Medigap Plan D and Medigap Plan F
  • You can buy Medicare Supplement coverage in Tupper Lake, New York if you have original Medicare and want coverage for out-of-pocket costs
  • Medicare Advantage plans are available in Tupper Lake with both PPO and HMO networks

If you’re eligible for Medicare in Tupper Lake, New York, you have a lot of choices. Major health insurance companies provide Tupper Lake, New York Medicare Advantage plans with a variety of coverage options to choose from. You can choose a plan that includes Tupper Lake, NY Part D coverage, or buy prescription coverage as a standalone policy.

Tupper Lake, New York Medicare Supplement plans are available from a number of companies if you choose to stick with original Medicare. These plans can pay for the out-of-pocket costs that Tupper Lake original Medicare plans don’t cover, like coinsurance and deductibles.

Ready to buy Tupper Lake, New York Medicare coverage? Enter your ZIP code to compare Tupper Lake, NY Medicare options available to you right now.

Medicare Advantage Companies in Tupper Lake, New York

Medicare Advantage in Tupper Lake, New York is offered by some of the same local health insurance companies you may have been covered by before. Take a look at which companies in Tupper Lake, NY offer Medicare Advantage as well as which plans they offer to find the coverage and provider network that’s best for you.

Medicare Advantage Companies in Tupper Lake, New York

Plan Name Monthly Prem. (Parts C & D) Deductible Additional Gap Coverage Preferred Pharmacy Copay/ Coinsurance 30-Day Supply MOOP for Part A & B Benefits
Aetna Medicare Assure Plan (HMO D-SNP) – H3312-070-0 $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: $0.00, Preferred Brand: $47.00, Non-Preferred Drug: $100.00, Specialty Tier: 29% N/A
Aetna Medicare Credit Plan (PPO) – H5521-313-0 $0.00 $250 . Tier 1 and 2 exempt Yes, some additional gap coverage. Preferred Generic: $0.00, Generic: $5.00, Preferred Brand: $47.00, Non-Preferred Drug: $100.00, Specialty Tier: 28% $7,550
Aetna Medicare Eagle Plan (PPO) – H5521-323-0 $0.00 No Rx Coverage No Rx Coverage This Plan does NOT include Prescription Drug coverage. $7,550
Aetna Medicare Premier Plan (PPO) – H5521-077-0 $0.00 $200 . Tier 1 and 2 exempt Yes, some additional gap coverage. Preferred Generic: $0.00, Generic: $10.00, Preferred Brand: $47.00, Non-Preferred Drug: $100.00, Specialty Tier: 29% $7,550
Aetna Medicare Value Plan (HMO) – H3312-048-0 $0.00 $0 Yes, some additional gap coverage. Preferred Generic: $2.00, Generic: $5.00, Preferred Brand: $47.00, Non-Preferred Drug: $100.00, Specialty Tier: 33% $7,550
CDPHP $0 Medicare Rx (HMO) – H3388-014-0 $0.00 $300 . Tier 1 and 2 exempt No additional gap coverage, only the Donut Hole Discount Preferred Generic: $3.00, Generic: $17.00, Preferred Brand: $47.00, Non-Preferred Drug: $100.00, Specialty Tier: 27% $7,500
CDPHP Basic RX (HMO) – H3388-013-0 $31.00 $0 No additional gap coverage, only the Donut Hole Discount Preferred Generic: $3.00, Generic: $15.00, Preferred Brand: $45.00, Non-Preferred Drug: $97.00, Specialty Tier: 33% $6,700
CDPHP Choice (HMO) – H3388-001-0 $39.90 No Rx Coverage No Rx Coverage This Plan does NOT include Prescription Drug coverage. $5,000
CDPHP Choice Rx (HMO) – H3388-002-0 $130.00 $0 No additional gap coverage, only the Donut Hole Discount Preferred Generic: $0.00, Generic: $11.00, Preferred Brand: $40.00, Non-Preferred Drug: $90.00, Specialty Tier: 33% $5,000
CDPHP Flex (PPO) – H5042-012-0 $0.00 No Rx Coverage No Rx Coverage This Plan does NOT include Prescription Drug coverage. $5,500
CDPHP Flex Rx (PPO) – H5042-011-0 $41.80 $0 No additional gap coverage, only the Donut Hole Discount Preferred Generic: $2.00, Generic: $14.00, Preferred Brand: $44.00, Non-Preferred Drug: $95.00, Specialty Tier: 33% $5,500
CDPHP Value Rx (HMO) – H3388-004-0 $60.80 $0 No additional gap coverage, only the Donut Hole Discount Preferred Generic: $2.00, Generic: $13.00, Preferred Brand: $42.00, Non-Preferred Drug: $93.00, Specialty Tier: 33% $5,800
CDPHP Vital Rx (PPO) – H5042-009-0 $0.00 $350 . Tier 1 and 2 exempt No additional gap coverage, only the Donut Hole Discount Preferred Generic: $3.00, Generic: $17.00, Preferred Brand: $47.00, Non-Preferred Drug: $100.00, Specialty Tier: 26% $7,500
Fidelis Dual Advantage (HMO D-SNP) – H5599-006-0 $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: 47%, Specialty Tier: 25% N/A
Fidelis Dual Advantage Flex (HMO D-SNP) – H5599-001-0 $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: 24%, Non-Preferred Drug: 39%, Specialty Tier: 25% N/A
MVP Medicare Preferred Gold with Part D (HMO-POS) – H3305-021-0 $140.00 $0 Yes, some additional gap coverage. Preferred Generic: $0.00, Generic: $10.00, Preferred Brand: $35.00, Non-Preferred Drug: 27%, Specialty Tier: 33% $5,800
MVP Medicare Preferred Gold without Part D (HMO-POS) – H3305-020-0 $62.00 No Rx Coverage No Rx Coverage This Plan does NOT include Prescription Drug coverage. $7,550
MVP Medicare Secure Plus with Part D (HMO-POS) – H3305-022-0 $90.00 $0 Yes, some additional gap coverage. Preferred Generic: $0.00, Generic: $15.00, Preferred Brand: $45.00, Non-Preferred Drug: 27%, Specialty Tier: 33% $7,550
MVP Medicare Secure with Part D (HMO-POS) – H3305-032-0 $40.00 $150 . Tier 1 and 2 exempt No additional gap coverage, only the Donut Hole Discount Preferred Generic: $0.00, Generic: $10.00, Preferred Brand: $47.00, Non-Preferred Drug: 26%, Specialty Tier: 30% $7,550
MVP Medicare WellSelect Plus with Part D (PPO) – H9615-007-0 $116.00 $0 Yes, some additional gap coverage. Preferred Generic: $0.00, Generic: $10.00, Preferred Brand: $35.00, Non-Preferred Drug: 27%, Specialty Tier: 33% $6,500
MVP Medicare WellSelect with Part D (PPO) – H9615-008-0 $0.00 $325 . Tier 1 and 2 exempt No additional gap coverage, only the Donut Hole Discount Preferred Generic: $0.00, Generic: $12.00, Preferred Brand: $47.00, Non-Preferred Drug: 25%, Specialty Tier: 27% $7,550
MVP SmartFund (MSA) – H5613-002-0 $0.00 No Rx Coverage No Rx Coverage This Plan does NOT include Prescription Drug coverage. N/A
Medicare BlueBasic (PPO) – H3335-044-0 $61.00 No Rx Coverage No Rx Coverage This Plan does NOT include Prescription Drug coverage. $4,500
Medicare BluePlus (PPO) – H3335-018-0 $130.00 $445 No additional gap coverage, only the Donut Hole Discount Preferred Generic: $8.00, Generic: $15.00, Preferred Brand: $40.00, Non-Preferred Drug: $95.00, Specialty Tier: 25% $6,000
UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO) – R5342-001-0 $16.00 $300 . Tier 1 and 2 exempt No additional gap coverage, only the Donut Hole Discount Preferred Generic: $3.00, Generic: $12.00, Preferred Brand: $47.00, Non-Preferred Drug: $100.00, Specialty Tier: 27% $6,700
UnitedHealthcare Medicare Advantage Choice Plan 3 (Regional PPO) – R5342-005-0 $46.00 $275 . Tier 1 and 2 exempt No additional gap coverage, only the Donut Hole Discount Preferred Generic: $3.00, Generic: $12.00, Preferred Brand: $47.00, Non-Preferred Drug: $100.00, Specialty Tier: 28% $6,700
UnitedHealthcare Medicare Advantage Choice Plan 4 (Regional PPO) – R5342-006-0 $84.00 $150 . Tier 1 and 2 exempt No additional gap coverage, only the Donut Hole Discount Preferred Generic: $3.00, Generic: $12.00, Preferred Brand: $47.00, Non-Preferred Drug: $100.00, Specialty Tier: 30% $6,700
UnitedHealthcare Medicare Advantage Patriot (Regional PPO) – R5342-002-0 $0.00 No Rx Coverage No Rx Coverage This Plan does NOT include Prescription Drug coverage. $6,700
WellCare Absolute (PPO) – H2775-111-0 $0.00 $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% $7,550
WellCare Imperial (PPO D-SNP) – H2775-112-0 $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: $9.00, Preferred Brand: $45.00, Non-Preferred Drug: 49%, Specialty Tier: 25% N/A
WellCare Summit (PPO) – H2775-113-0 $5.10 $445 . Tier 1 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% $6,700
WellCare Today’s Options Advantage 300 (PPO) – H2775-108-0 $0.00 No Rx Coverage No Rx Coverage This Plan does NOT include Prescription Drug coverage. $6,700
WellCare Today’s Options Advantage Plus 150A (PPO) – H2775-105-0 $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: $75.00, Specialty Tier: 33% $3,400
WellCare Today’s Options Advantage Plus 550B (PPO) – H2775-106-0 $0.00 $0 Yes, some additional gap coverage. Preferred Generic: $0.00, Generic: $7.00, Preferred Brand: $37.00, Non-Preferred Drug: $90.00, Specialty Tier: 33% $6,700
WellCare Today’s Options Premier 200 (PFFS) – H2816-037-0 $71.00 No Rx Coverage No Rx Coverage This Plan does NOT include Prescription Drug coverage. N/A
WellCare Today’s Options Premier 300 (PFFS) – H2816-038-0 $0.00 No Rx Coverage No Rx Coverage This Plan does NOT include Prescription Drug coverage. N/A

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Medicare Supplement Companies in Tupper Lake, New York

Original Medicare leaves you with some out-of-pocket costs such as deductibles and coinsurance. With Tupper Lake, New York Medicare Supplement plan, you can get coverage for some or all of those costs. Medicare Supplement plans in New York are standardized, but companies can choose which plans they will sell. Take a look at which companies sell Medicare Supplement (Medigap) insurance and which plans they offer.

Medicare Supplement Companies in Tupper Lake, New York

Company Plans
AARP – UnitedHealthcare Insurance Company of New York (Standard) Medigap Plan A,
Medigap Plan B,
Medigap Plan C,
Medigap Plan F,
Medigap Plan G,
Medigap Plan L,
Medigap Plan N
BlueShield of Northeastern New York Medigap Plan A,
Medigap Plan B,
Medigap Plan C,
Medigap Plan F,
Medigap Plan F-high deductible,
Medigap Plan G,
Medigap Plan N
EmblemHealth Services Company Medigap Plan A,
Medigap Plan B,
Medigap Plan C,
Medigap Plan F
Empire BlueCross New York Medigap Plan A,
Medigap Plan B,
Medigap Plan F,
Medigap Plan G,
Medigap Plan N
Globe Life Insurance Company of New York Medigap Plan A,
Medigap Plan B,
Medigap Plan C,
Medigap Plan D,
Medigap Plan F,
Medigap Plan F-high deductible,
Medigap Plan G,
Medigap Plan G-high deductible,
Medigap Plan L,
Medigap Plan N
Humana (Humana Insurance Company of New York) Medigap Plan A,
Medigap Plan B,
Medigap Plan C,
Medigap Plan F,
Medigap Plan F-high deductible,
Medigap Plan G,
Medigap Plan G-high deductible,
Medigap Plan L,
Medigap Plan N
Mutual of Omaha Insurance Company Medigap Plan A,
Medigap Plan B,
Medigap Plan C,
Medigap Plan D,
Medigap Plan F,
Medigap Plan G
State Farm Mutual Automobile Insurance Company Medigap Plan A,
Medigap Plan B,
Medigap Plan C,
Medigap Plan F

Tupper Lake, New York Standard Medicare Plan Coverage

Wondering what’s covered by each of the standard New York Medicare Supplement plans? Take a look at all of the Tupper Lake, New York Medicare Supplement plans with coverage details.

Tupper Lake, New York Standard Medicare Plan Coverage

Plan Name Monthly Cost Copays Coinsurance Deductibles Plan Benefits
Medigap Plan A Premiums range from $169-$350 depending on your age, sex, health status, and when you buy. $0 is generally your cost for approved Part B services. $1,484 Hospital (Part A) deductible,
$203 Medical (Part B) deductible
Skilled nursing facility: No
Part A deductible: No
Part B deductible: No
Part B excess charges: No
Foreign travel emergency: No
Medigap Plan B Premiums range from $226-$510 depending on your age, sex, health status, and when you buy. $0 is generally your cost for approved Part B services. $0 Hospital (Part A) deductible,
$203 Medical (Part B) deductible
Skilled nursing facility: No
Part A deductible: Yes
Part B deductible: No
Part B excess charges: No
Foreign travel emergency: No
Medigap Plan C Premiums range from $301-$511 depending on your age, sex, health status, and when you buy. $0 is generally your cost for approved Part B services. $0 Hospital (Part A) deductible,
$0 Medical (Part B) deductible
Skilled nursing facility: Yes
Part A deductible: Yes
Part B deductible: Yes
Part B excess charges: No
Foreign travel emergency: Yes
Medigap Plan D Premiums range from $391-$502 depending on your age, sex, health status, and when you buy. $0 is generally your cost for approved Part B services. $0 Hospital (Part A) deductible,
$203 Medical (Part B) deductible
Skilled nursing facility: Yes
Part A deductible: Yes
Part B deductible: No
Part B excess charges: No
Foreign travel emergency: Yes
Medigap Plan F Premiums range from $305-$514 depending on your age, sex, health status, and when you buy. $0 is generally your cost for approved Part B services. $0 Hospital (Part A) deductible,
$0 Medical (Part B) deductible
Skilled nursing facility: Yes
Part A deductible: Yes
Part B deductible: Yes
Part B excess charges: Yes
Foreign travel emergency: Yes
Medigap Plan F-high deductible Premiums range from $69-$91 depending on your age, sex, health status, and when you buy. $0 is generally your cost for approved Part B services after you pay $2,370 deductible. $2,370 total plan deductible.
After, you pay: $0 Hospital (Part A) deductible,
$0 Medical (Part B) deductible
Skilled nursing facility: Yes
Part A deductible: Yes
Part B deductible: Yes
Part B excess charges: Yes
Foreign travel emergency: Yes
Medigap Plan G Premiums range from $268-$476 depending on your age, sex, health status, and when you buy. $0 is generally your cost for approved Part B services. $0 Hospital (Part A) deductible,
$203 Medical (Part B) deductible
Skilled nursing facility: Yes
Part A deductible: Yes
Part B deductible: No
Part B excess charges: Yes
Foreign travel emergency: Yes
Medigap Plan G-high deductible Premiums range from $69-$91 depending on your age, sex, health status, and when you buy. $0 is generally your cost for approved Part B services after you pay $2,370 deductible. $2,370 total plan deductible.
After, you pay: $0 Hospital (Part A) deductible,
$203 Medical (Part B) deductible
Skilled nursing facility: Yes
Part A deductible: Yes
Part B deductible: No
Part B excess charges: Yes
Foreign travel emergency: Yes
Medigap Plan K Premiums range from $86-$207 depending on your age, sex, health status, and when you buy. 10% is generally your cost for approved Part B services up to $6,220. Then, you’ll pay $0 for the rest of the year. $742 (50% of Part A deductible) Hospital (Part A) deductible,
$203 Medical (Part B) deductible
Skilled nursing facility: Yes
Part A deductible: Yes
Part B deductible: No
Part B excess charges: No
Foreign travel emergency: No
Medigap Plan L Premiums range from $181-$297 depending on your age, sex, health status, and when you buy. 5% is generally your cost for approved Part B services up to $3,110. Then, you’ll pay $0 for the rest of the year. $371 (25% of Part A deductible) Hospital (Part A) deductible,
$203 Medical (Part B) deductible
Skilled nursing facility: Yes
Part A deductible: Yes
Part B deductible: No
Part B excess charges: No
Foreign travel emergency: No
Medigap Plan M Premiums range from $524-$524 depending on your age, sex, health status, and when you buy. $0 is generally your cost for approved Part B services. $742 (50% of Part A deductible) Hospital (Part A) deductible,
$203 Medical (Part B) deductible
Skilled nursing facility: Yes
Part A deductible: Yes
Part B deductible: No
Part B excess charges: No
Foreign travel emergency: Yes
Medigap Plan N Premiums range from $190-$282 depending on your age, sex, health status, and when you buy. $0 is generally your cost for approved Part B services with some $20 and $50 copays. $0 Hospital (Part A) deductible,
$203 Medical (Part B) deductible
Skilled nursing facility: Yes
Part A deductible: Yes
Part B deductible: No
Part B excess charges: No
Foreign travel emergency: Yes

Standalone Medicare Part D Plans in Tupper Lake, New York

Prescription drug coverage for Medicare in Tupper Lake, New York is covered by a Part D plan. You can purchase Part D coverage in Tupper Lake, New York as a standalone plan if it’s not included in your Medicare Advantage coverage. Take a look at the options for standalone Part D plans here.

Standalone Medicare Part D Plans in Tupper Lake, New York

Plan Details Tiers
SilverScript SmartRx (PDP)
S5601 – 178 – 0
by Aetna Medicare
Monthly Premium: $7.30
Annual Deductible: $445
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $0.00
Tier 2: $19.00
Tier 3: $46.00
Tier 4: 49%
Tier 5: 25%
Elixir RxPlus (PDP)
S7694 – 121 – 0
by Elixir Insurance
Monthly Premium: $15.60
Annual Deductible: $445
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $1.00
Tier 2: $6.00
Tier 3: $43.00
Tier 4: 45%
Tier 5: 25%
WellCare Wellness Rx (PDP)
S4802 – 172 – 0
by WellCare
Monthly Premium: $15.60
Annual Deductible: $445
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $0.00
Tier 2: $5.00
Tier 3: $40.00
Tier 4: 46%
Tier 5: 25%
Humana Walmart Value Rx Plan (PDP)
S5552 – 006 – 0
by Humana
Monthly Premium: $17.20
Annual Deductible: $445
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $1.00
Tier 2: $4.00
Tier 3: 16%
Tier 4: 35%
Tier 5: 25%
WellCare Value Script (PDP)
S4802 – 138 – 0
by WellCare
Monthly Premium: $17.70
Annual Deductible: $445
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $0.00
Tier 2: $6.00
Tier 3: $43.00
Tier 4: 47%
Tier 5: 25%
Express Scripts Medicare – Saver (PDP)
S5983 – 007 – 0
by Express Scripts Medicare
Monthly Premium: $23.60
Annual Deductible: $285
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $2.00
Tier 2: $7.00
Tier 3: $35.00
Tier 4: 50%
Tier 5: 28%
Cigna Secure-Essential Rx (PDP)
S5617 – 282 – 0
by Cigna
Monthly Premium: $24.00
Annual Deductible: $445
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $0.00
Tier 2: $2.00
Tier 3: 18%
Tier 4: 40%
Tier 5: 25%
Blue Rx Enhanced (PDP)
S3375 – 003 – 0
by BlueCross BlueShield: Empire, Excellus, WNY & NEN
Monthly Premium: $30.70
Annual Deductible: $325
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: Yes
Tier 1: $0.00
Tier 2: $3.00
Tier 3: 20%
Tier 4: 39%
Tier 5: 27%
Express Scripts Medicare – Value (PDP)
S5983 – 004 – 0
by Express Scripts Medicare
Monthly Premium: $33.20
Annual Deductible: $445
Zero Premium If Full LIS Benefits: Yes
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $1.00
Tier 2: $3.00
Tier 3: $20.00
Tier 4: 46%
Tier 5: 25%
WellCare Classic (PDP)
S4802 – 077 – 0
by WellCare
Monthly Premium: $34.80
Annual Deductible: $445
Zero Premium If Full LIS Benefits: Yes
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $0.00
Tier 2: $4.00
Tier 3: $30.00
Tier 4: 33%
Tier 5: 25%
SilverScript Choice (PDP)
S5601 – 006 – 0
by Aetna Medicare
Monthly Premium: $35.00
Annual Deductible: $290
Zero Premium If Full LIS Benefits: Yes
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $0.00
Tier 2: $5.00
Tier 3: $35.00
Tier 4: 40%
Tier 5: 27%
Elixir RxSecure (PDP)
S7694 – 003 – 0
by Elixir Insurance
Monthly Premium: $35.80
Annual Deductible: $445
Zero Premium If Full LIS Benefits: Yes
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $1.00
Tier 2: $7.00
Tier 3: 15%
Tier 4: 34%
Tier 5: 25%
WellCare Medicare Rx Saver (PDP)
S5810 – 037 – 0
by WellCare
Monthly Premium: $36.80
Annual Deductible: $445
Zero Premium If Full LIS Benefits: Yes
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $0.00
Tier 2: $2.00
Tier 3: $42.00
Tier 4: 35%
Tier 5: 25%
Humana Basic Rx Plan (PDP)
S5552 – 004 – 0
by Humana
Monthly Premium: $37.10
Annual Deductible: $445
Zero Premium If Full LIS Benefits: Yes
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $0.00
Tier 2: $1.00
Tier 3: 20%
Tier 4: 35%
Tier 5: 25%
Cigna Secure Rx (PDP)
S5617 – 013 – 0
by Cigna
Monthly Premium: $38.30
Annual Deductible: $445
Zero Premium If Full LIS Benefits: Yes
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $1.00
Tier 2: $2.00
Tier 3: $25.00
Tier 4: 50%
Tier 5: 25%
WellCare Medicare Rx Select (PDP)
S5810 – 277 – 0
by WellCare
Monthly Premium: $40.20
Annual Deductible: $300
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $0.00
Tier 2: $3.00
Tier 3: $47.00
Tier 4: 42%
Tier 5: 27%
AARP MedicareRx Walgreens (PDP)
S5921 – 382 – 0
by UnitedHealthcare
Monthly Premium: $40.90
Annual Deductible: $445
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $0.00
Tier 2: $6.00
Tier 3: $40.00
Tier 4: 40%
Tier 5: 25%
Blue Rx Standard (PDP)
S3375 – 001 – 0
by BlueCross BlueShield: Empire, Excellus, WNY & NEN
Monthly Premium: $49.10
Annual Deductible: $440
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $1.00
Tier 2: $2.00
Tier 3: $34.00
Tier 4: 32%
Tier 5: 25%
EmblemHealth VIP Rx (PDP)
S5966 – 003 – 0
by EmblemHealth Medicare PDP
Monthly Premium: $49.30
Annual Deductible: $445
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $2.00
Tier 2: $12.00
Tier 3: $40.00
Tier 4: 33%
Tier 5: 25%
Cigna Secure-Extra Rx (PDP)
S5617 – 248 – 0
by Cigna
Monthly Premium: $50.00
Annual Deductible: $100
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: Yes
Tier 1: $4.00
Tier 2: $10.00
Tier 3: $42.00
Tier 4: 50%
Tier 5: 31%
AARP MedicareRx Saver Plus (PDP)
S5921 – 379 – 0
by UnitedHealthcare
Monthly Premium: $70.10
Annual Deductible: $445
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $1.00
Tier 2: $8.00
Tier 3: $31.00
Tier 4: 40%
Tier 5: 25%
Humana Premier Rx Plan (PDP)
S5552 – 005 – 0
by Humana
Monthly Premium: $72.30
Annual Deductible: $445
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $1.00
Tier 2: $4.00
Tier 3: $45.00
Tier 4: 39%
Tier 5: 25%
EmblemHealth VIP Rx Plus (PDP)
S5966 – 004 – 0
by EmblemHealth Medicare PDP
Monthly Premium: $72.50
Annual Deductible: $285
Zero Premium If Full LIS Benefits: No
ICL: $3,970
Additional Gap Coverage: No
Tier 1: $0.00
Tier 2: $0.00
Tier 3: $35.00
Tier 4: $95.00
Tier 5: 28%
Blue Rx Plus (PDP)
S3375 – 002 – 0
by BlueCross BlueShield: Empire, Excellus, WNY & NEN
Monthly Premium: $72.70
Annual Deductible: $0
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $1.00
Tier 2: $3.00
Tier 3: $43.00
Tier 4: 45%
Tier 5: 33%
SilverScript Plus (PDP)
S5601 – 007 – 0
by Aetna Medicare
Monthly Premium: $76.60
Annual Deductible: $0
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: Yes
Tier 1: $0.00
Tier 2: $2.00
Tier 3: $47.00
Tier 4: 48%
Tier 5: 33%
WellCare Medicare Rx Value Plus (PDP)
S5768 – 200 – 0
by WellCare
Monthly Premium: $82.00
Annual Deductible: $0
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $1.00
Tier 2: $4.00
Tier 3: $47.00
Tier 4: 43%
Tier 5: 33%
Express Scripts Medicare – Choice (PDP)
S5983 – 006 – 0
by Express Scripts Medicare
Monthly Premium: $87.60
Annual Deductible: $100
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: Yes
Tier 1: $2.00
Tier 2: $7.00
Tier 3: $42.00
Tier 4: 50%
Tier 5: 31%
AARP MedicareRx Preferred (PDP)
S5805 – 001 – 0
by UnitedHealthcare
Monthly Premium: $94.80
Annual Deductible: $0
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $5.00
Tier 2: $10.00
Tier 3: $45.00
Tier 4: 40%
Tier 5: 33%

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