PEGASYS PROCLICK 180 MCG/0.5 (0.5 ML ) (NDC: 00004036530)
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 |
AARP MedicareComplete Mosaic (HMO)
|
$0.00 |
$150* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | 33% | P | $3,492.73 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$260* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | 33% | P | $3,492.73 |
Browse Plan Formulary |
Advantage Care (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | 33% | P | $3,479.40 |
Browse Plan Formulary |
AgeWell New York FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | None | $3,511.63 |
Browse Plan Formulary |
AlphaCare Renew (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $3,479.49 |
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 |
AlphaCare Signature FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | n/a | P | $3,479.49 |
Browse Plan Formulary |
Amerivantage Balance + Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $3,472.58 |
Browse Plan Formulary |
Amerivantage Specialty + Rx (HMO SNP)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $3,480.52 |
Browse Plan Formulary |
Amida Care True Life Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | 33% | Q:4 /28Days | $3,472.58 |
Browse Plan Formulary |
CenterLight Healthcare FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | Q:4 /28Days | $3,490.97 |
Browse Plan Formulary |
Easy Choice Diamond Rewards (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | 33% | P | $3,436.62 |
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 |
Easy Choice Rewards (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | 33% | P | $3,436.62 |
Browse Plan Formulary |
Empire Dual Advantage (HMO SNP)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $3,486.87 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$257* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | n/a | P | $3,436.81 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$257* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | n/a | P | $3,520.15 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$257* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | n/a | P | $3,508.80 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$257* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | n/a | P | $3,515.88 |
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 |
FIDA Care Complete (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | n/a | P | $3,479.40 |
Browse Plan Formulary |
Fidelis Medicare $0 Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $3,515.56 |
Browse Plan Formulary |
HealthPlus Amerigroup FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | P | $3,472.58 |
Browse Plan Formulary |
Humana Gold Plus H3533-016 (HMO)
|
$0.00 |
$320 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P Q:2 /28Days | $3,525.19 |
Browse Plan Formulary |
ICS Community Care Plus FIDA MMP (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | P | $3,474.78 |
Browse Plan Formulary |
Integra FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | P | $3,481.50 |
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 |
Liberty Health Advantage Preferred Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:2 /28Days | $3,599.30 |
Browse Plan Formulary |
RiverSpring FIDA Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | P | $3,725.40 |
Browse Plan Formulary |
SWH Whole Health FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | Q:4 /28Days | $3,469.68 |
Browse Plan Formulary |
Touchstone Health Medicare Freedom (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P Q:2 /28Days | $3,599.30 |
Browse Plan Formulary |
Touchstone Health Medicare Power (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P Q:2 /28Days | $3,599.30 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (Regional PPO)
|
$0.00 |
$225* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | 33% | P | $3,499.70 |
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 |
VillageCareMAX Full Advantage FIDA (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | P | $3,479.49 |
Browse Plan Formulary |
VNSNY CHOICE FIDA Complete (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | P | $3,450.74 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Enhanced (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P | $3,450.82 |
Browse Plan Formulary |
Fidelis Long Term Care Advantage (HMO SNP)
|
$3.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $3,515.63 |
Browse Plan Formulary |
Access Medicare Gold (HMO)
|
$12.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P | $3,481.40 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H3533-018 (HMO SNP)
|
$28.70 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:2 /28Days | $3,525.19 |
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 |
AARP MedicareComplete Plan 1 (HMO)
|
$29.00 |
$230* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | 33% | P | $3,492.73 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$30.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $3,494.71 |
Browse Plan Formulary |
LiveWell (HMO)
|
$32.90 |
$250 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | 25% | None | $3,511.63 |
Browse Plan Formulary |
Fidelis Dual Advantage (HMO SNP)
|
$33.10 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $3,515.56 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Classic (HMO)
|
$34.10 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $3,450.82 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO SNP)
|
$35.40 |
$320 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $3,515.58 |
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 |
AlphaCare Resilience (HMO SNP)
|
$36.10 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | n/a | P | $3,479.49 |
Browse Plan Formulary |
AlphaCare Total (HMO SNP)
|
$36.20 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | n/a | P | $3,479.49 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Preferred (HMO SNP)
|
$36.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | P | $3,450.82 |
Browse Plan Formulary |
Access Medicare Pearl (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | P | $3,481.40 |
Browse Plan Formulary |
Access Medicare Platinum (HMO)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $3,481.40 |
Browse Plan Formulary |
Amida Care Live Life Advantage (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | Q:4 /28Days | $3,472.58 |
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 |
Amida Care True Life Advantage (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | Q:4 /28Days | $3,472.58 |
Browse Plan Formulary |
BeWell (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $3,511.63 |
Browse Plan Formulary |
CareWell (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $3,511.63 |
Browse Plan Formulary |
CenterLight Healthcare Direct Complete Plan (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
25% | 25% | Q:4 /28Days | $3,490.97 |
Browse Plan Formulary |
FeelWell (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $3,511.63 |
Browse Plan Formulary |
Fidelis Medicaid Advantage Plus (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $3,515.63 |
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 |
Fidelis Medicare Advantage Flex (HMO-POS)
|
$36.90 |
$240 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $3,515.58 |
Browse Plan Formulary |
Liberty Health Advantage Dual Power (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | P Q:2 /28Days | $3,599.30 |
Browse Plan Formulary |
Senior Whole Health of New York NHC (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | Q:4 /28Days | $3,470.63 |
Browse Plan Formulary |
Touchstone Health Medicare Grand (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P Q:2 /28Days | $3,599.30 |
Browse Plan Formulary |
Touchstone Health Medicare Prestige (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P Q:2 /28Days | $3,599.30 |
Browse Plan Formulary |
Touchstone Health Medicare Total (HMO)
|
$36.90 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P Q:2 /28Days | $3,599.30 |
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 |
UnitedHealthcare Dual Complete (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P | $3,494.59 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Maximum (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P | $3,450.82 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO SNP)
|
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P | $3,450.82 |
Browse Plan Formulary |
Empire MediBlue Freedom I (PPO)
|
$71.00 |
$304* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | n/a | P | $3,468.64 |
Browse Plan Formulary |