PEGASYS INJECTION (1 ML X 1 VIALSU BOX ) (NDC: 00004035009)
2015 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
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 |
Commonwealth Care Alliance (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand Drugs |
0% | 0% | None | $3,595.81 |
Browse Plan Formulary |
Fallon Senior Plan Super Saver Rx (HMO)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | P | $3,750.30 |
Browse Plan Formulary |
Fallon Senior Plan Super Saver Rx (HMO)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | P | $3,536.83 |
Browse Plan Formulary |
Fallon Senior Plan Super Saver Rx (HMO)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | P | $3,517.79 |
Browse Plan Formulary |
Fallon Senior Plan Super Saver Rx (HMO)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | P | $3,750.30 |
Browse Plan Formulary |
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 |
Fallon Senior Plan Super Saver Rx (HMO)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | P | $3,750.30 |
Browse Plan Formulary |
Medicare PPO Blue SaverRx (PPO)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | P Q:4 /28Days | $3,551.32 |
Browse Plan Formulary |
Tufts Health Unify (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Brand Drugs |
0% | 0% | P Q:4 /28Days | $3,542.52 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | 29% | P Q:4 /28Days | $3,836.13 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | 29% | P Q:4 /28Days | $3,553.06 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | 29% | P Q:4 /28Days | $3,540.90 |
Browse Plan Formulary |
|
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 |
HNE Medicare Value (HMO)
|
$20.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
29% | n/a | P Q:4 /28Days | $3,654.49 |
Browse Plan Formulary |
Fallon Senior Plan Saver Enhanced RX (HMO)
|
$26.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P | $3,750.30 |
Browse Plan Formulary |
Fallon Senior Plan Saver Enhanced RX (HMO)
|
$26.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P | $3,536.83 |
Browse Plan Formulary |
Fallon Senior Plan Saver Enhanced RX (HMO)
|
$26.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P | $3,517.79 |
Browse Plan Formulary |
Fallon Senior Plan Saver Enhanced RX (HMO)
|
$26.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P | $3,750.30 |
Browse Plan Formulary |
Medicare HMO Blue ValueRx (HMO)
|
$27.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | P Q:4 /28Days | $3,551.32 |
Browse Plan Formulary |
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 Care Options Program (HMO SNP)
|
$29.60 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $3,595.81 |
Browse Plan Formulary |
Tufts Health Plan Senior Care Options (HMO SNP)
|
$29.60 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P Q:4 /28Days | $3,542.52 |
Browse Plan Formulary |
NaviCare (HMO SNP)
|
$29.70 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
25% | 25% | P | $3,515.06 |
Browse Plan Formulary |
AARP MedicareComplete Choice (Regional PPO)
|
$29.90 |
$255* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | 33% | P | $3,489.19 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$46.30 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P Q:4 /28Days | $3,836.13 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$46.30 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P Q:4 /28Days | $3,553.06 |
Browse Plan Formulary |
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 |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$46.30 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P Q:4 /28Days | $3,540.90 |
Browse Plan Formulary |
Medicare PPO Blue ValueRx (PPO)
|
$49.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | P Q:4 /28Days | $3,551.32 |
Browse Plan Formulary |
HNE Medicare Basic (HMO)
|
$75.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Specialty Tier |
33% | n/a | P Q:4 /28Days | $3,654.49 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$76.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P Q:4 /28Days | $3,553.06 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$76.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P Q:4 /28Days | $3,540.90 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$76.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P Q:4 /28Days | $3,836.13 |
Browse Plan Formulary |
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 |
Fallon Senior Plan Plus Enhanced Rx (HMO-POS)
|
$106.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P | $3,750.30 |
Browse Plan Formulary |
HNE Medicare Plus (HMO)
|
$106.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Specialty Tier |
33% | n/a | P Q:4 /28Days | $3,654.49 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$110.20 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | P Q:4 /28Days | $3,540.90 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$110.20 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | P Q:4 /28Days | $3,836.13 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$110.20 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | P Q:4 /28Days | $3,553.06 |
Browse Plan Formulary |
Medicare PPO Blue PlusRx (PPO)
|
$153.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | 28% | P Q:4 /28Days | $3,551.32 |
Browse Plan Formulary |
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 |
HNE Medicare Premium (HMO)
|
$156.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Specialty Tier |
33% | n/a | P Q:4 /28Days | $3,654.49 |
Browse Plan Formulary |
Medicare HMO Blue PlusRx (HMO)
|
$193.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | 28% | P Q:4 /28Days | $3,551.32 |
Browse Plan Formulary |
HNE Medicare Freedom (HMO-POS)
|
$210.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Tier 4 |
33% | n/a | P Q:4 /28Days | $3,654.49 |
Browse Plan Formulary |