SIMPONI 50 MG/0.5 ML PEN INJEC (0.5 ML ) (NDC: 57894007002)
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)
![Email Prescription and/or Health Benefit details for AARP MedicareComplete Mosaic (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$150* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | 33% | P | $3,299.80 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
![Email Prescription and/or Health Benefit details for AARP MedicareComplete Plan 2 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$260* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | 33% | P | $3,299.80 |
Browse Plan Formulary |
Advantage Care (HMO)
![Email Prescription and/or Health Benefit details for Advantage Care (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
33% | 33% | P Q:1 /28Days | $3,298.30 |
Browse Plan Formulary |
AlphaCare Renew (HMO)
![Email Prescription and/or Health Benefit details for AlphaCare Renew (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $3,291.35 |
Browse Plan Formulary |
AlphaCare Signature FIDA Plan (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for AlphaCare Signature FIDA Plan (Medicare-Medicaid Plan)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | n/a | P Q:1 /28Days | $3,291.35 |
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 |
Amerivantage Balance + Rx (HMO)
![Email Prescription and/or Health Benefit details for Amerivantage Balance + Rx (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $3,319.62 |
Browse Plan Formulary |
Amerivantage Specialty + Rx (HMO SNP)
![Email Prescription and/or Health Benefit details for Amerivantage Specialty + Rx (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:1 /28Days | $3,314.28 |
Browse Plan Formulary |
Empire Dual Advantage (HMO SNP)
![Email Prescription and/or Health Benefit details for Empire Dual Advantage (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:1 /28Days | $3,318.99 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
![Email Prescription and/or Health Benefit details for Empire MediBlue Plus (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$257* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $3,293.73 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
![Email Prescription and/or Health Benefit details for Empire MediBlue Plus (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$257* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $3,316.23 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
![Email Prescription and/or Health Benefit details for Empire MediBlue Plus (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$257* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $3,325.91 |
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 |
Empire MediBlue Plus (HMO)
![Email Prescription and/or Health Benefit details for Empire MediBlue Plus (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$257* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $3,318.51 |
Browse Plan Formulary |
FIDA Care Complete (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for FIDA Care Complete (Medicare-Medicaid Plan)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | n/a | P Q:1 /28Days | $3,298.30 |
Browse Plan Formulary |
Fidelis Medicare $0 Premium (HMO)
![Email Prescription and/or Health Benefit details for Fidelis Medicare $0 Premium (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $3,320.62 |
Browse Plan Formulary |
HealthPlus Amerigroup FIDA Plan (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for HealthPlus Amerigroup FIDA Plan (Medicare-Medicaid Plan)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | P Q:1 /28Days | $3,319.62 |
Browse Plan Formulary |
ICS Community Care Plus FIDA MMP (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for ICS Community Care Plus FIDA MMP (Medicare-Medicaid Plan)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | P Q:1 /28Days | $3,291.35 |
Browse Plan Formulary |
Integra FIDA Plan (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for Integra FIDA Plan (Medicare-Medicaid Plan)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | P Q:1 /28Days | $3,302.80 |
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 |
RiverSpring FIDA Plan (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for RiverSpring FIDA Plan (Medicare-Medicaid Plan)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | P | $3,414.99 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (Regional PPO)
![Email Prescription and/or Health Benefit details for UnitedHealthcare MedicareComplete Choice (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$225* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | 33% | P | $3,298.82 |
Browse Plan Formulary |
VillageCareMAX Full Advantage FIDA (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for VillageCareMAX Full Advantage FIDA (Medicare-Medicaid Plan)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | P Q:1 /28Days | $3,291.35 |
Browse Plan Formulary |
VNSNY CHOICE FIDA Complete (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for VNSNY CHOICE FIDA Complete (Medicare-Medicaid Plan)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | P Q:1 /28Days | $3,257.49 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Enhanced (HMO)
![Email Prescription and/or Health Benefit details for VNSNY CHOICE Medicare Enhanced (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P Q:1 /28Days | $3,256.90 |
Browse Plan Formulary |
Fidelis Long Term Care Advantage (HMO SNP)
![Email Prescription and/or Health Benefit details for Fidelis Long Term Care Advantage (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$3.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $3,320.58 |
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 |
Access Medicare Gold (HMO)
![Email Prescription and/or Health Benefit details for Access Medicare Gold (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$12.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | P Q:1 /28Days | $3,287.58 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
![Email Prescription and/or Health Benefit details for AARP MedicareComplete Plan 1 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.00 |
$230* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | 33% | P | $3,299.80 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Nursing Home Plan (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$30.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $3,297.70 |
Browse Plan Formulary |
Fidelis Dual Advantage (HMO SNP)
![Email Prescription and/or Health Benefit details for Fidelis Dual Advantage (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$33.10 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $3,320.63 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Classic (HMO)
![Email Prescription and/or Health Benefit details for VNSNY CHOICE Medicare Classic (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$34.10 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:1 /28Days | $3,256.90 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO SNP)
![Email Prescription and/or Health Benefit details for Fidelis Dual Advantage Flex (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$35.40 |
$320 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $3,320.60 |
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)
![Email Prescription and/or Health Benefit details for AlphaCare Resilience (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.10 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | n/a | P Q:1 /28Days | $3,291.35 |
Browse Plan Formulary |
AlphaCare Total (HMO SNP)
![Email Prescription and/or Health Benefit details for AlphaCare Total (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.20 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | n/a | P Q:1 /28Days | $3,291.35 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Preferred (HMO SNP)
![Email Prescription and/or Health Benefit details for VNSNY CHOICE Medicare Preferred (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | P Q:1 /28Days | $3,256.90 |
Browse Plan Formulary |
Access Medicare Pearl (HMO SNP)
![Email Prescription and/or Health Benefit details for Access Medicare Pearl (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | P Q:1 /28Days | $3,287.58 |
Browse Plan Formulary |
Access Medicare Platinum (HMO)
![Email Prescription and/or Health Benefit details for Access Medicare Platinum (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P Q:1 /28Days | $3,287.58 |
Browse Plan Formulary |
Amida Care Live Life Advantage (HMO SNP)
![Email Prescription and/or Health Benefit details for Amida Care Live Life Advantage (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | 25% | P | $3,319.62 |
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 |
Amida Care True Life Advantage (HMO SNP)
![Email Prescription and/or Health Benefit details for Amida Care True Life Advantage (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | P | $3,319.62 |
Browse Plan Formulary |
Fidelis Medicaid Advantage Plus (HMO SNP)
![Email Prescription and/or Health Benefit details for Fidelis Medicaid Advantage Plus (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $3,320.64 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
![Email Prescription and/or Health Benefit details for Fidelis Medicare Advantage Flex (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.90 |
$240 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $3,320.59 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Dual Complete (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P | $3,299.47 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Maximum (HMO SNP)
![Email Prescription and/or Health Benefit details for VNSNY CHOICE Medicare Maximum (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P Q:1 /28Days | $3,256.90 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO SNP)
![Email Prescription and/or Health Benefit details for VNSNY CHOICE Total (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$36.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
$0.00 | $0.00 | P Q:1 /28Days | $3,256.90 |
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 |
Empire MediBlue Freedom I (PPO)
![Email Prescription and/or Health Benefit details for Empire MediBlue Freedom I (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$71.00 |
$304* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $3,317.99 |
Browse Plan Formulary |