PEGASYS INJECTION (1 ML X 1 VIALSU BOX ) (NDC: 00004035009)
2017 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 |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:4 /28Days | $4,066.65 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:4 /28Days | $3,887.39 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:4 /28Days | $3,887.39 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:4 /28Days | $4,066.65 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:4 /28Days | $4,066.65 |
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 |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | n/a | None | $4,069.94 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | n/a | None | $3,962.52 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | n/a | None | $4,069.94 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | n/a | None | $4,069.94 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | n/a | None | $4,069.94 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | n/a | None | $3,962.52 |
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 |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | n/a | None | $4,069.94 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | n/a | None | $4,069.94 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | n/a | None | $4,069.94 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | n/a | None | $4,069.94 |
Browse Plan Formulary |
HumanaChoice R5826-006 (Regional PPO)
|
$25.50 |
$400 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:4 /28Days | $3,839.09 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$30.50 |
$400 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | n/a | Q:4 /28Days | $4,066.93 |
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 |
Medicare Plus Blue PPO Essential (PPO)
|
$30.50 |
$400 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | n/a | Q:4 /28Days | $4,066.93 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$30.50 |
$400 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | n/a | Q:4 /28Days | $3,887.39 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$30.50 |
$400 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | n/a | Q:4 /28Days | $3,887.39 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$30.50 |
$400 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | n/a | Q:4 /28Days | $4,066.93 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$66.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
31% | n/a | None | $4,068.05 |
Browse Plan Formulary |
McLaren Advantage Sapphire (HMO)
|
$73.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 4 |
Specialty Tier |
29% | n/a | P | $4,087.37 |
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 |
McLaren Advantage Sapphire (HMO)
|
$73.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 4 |
Specialty Tier |
29% | n/a | P | $4,111.17 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$85.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
31% | n/a | None | $4,068.05 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$85.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
31% | n/a | None | $4,068.05 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$85.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
31% | n/a | None | $3,962.50 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$85.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
31% | n/a | None | $4,068.05 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$85.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
31% | n/a | None | $4,068.05 |
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 |
Medicare Plus Blue PPO Vitality (PPO)
|
$106.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | n/a | Q:4 /28Days | $4,066.93 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$106.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | n/a | Q:4 /28Days | $3,887.39 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$106.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | n/a | Q:4 /28Days | $3,887.39 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$106.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | n/a | Q:4 /28Days | $4,066.93 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$106.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | n/a | Q:4 /28Days | $4,066.93 |
Browse Plan Formulary |
McLaren Advantage Diamond (HMO)
|
$132.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 4 |
Specialty Tier |
29% | n/a | P | $4,087.37 |
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 |
McLaren Advantage Diamond (HMO)
|
$132.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 4 |
Specialty Tier |
29% | n/a | P | $4,111.17 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$154.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:4 /28Days | $3,887.39 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$154.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:4 /28Days | $4,066.65 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$154.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:4 /28Days | $3,887.39 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$154.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:4 /28Days | $4,066.65 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$154.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:4 /28Days | $4,066.65 |
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 |
PriorityMedicare (HMO-POS)
|
$155.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | None | $4,068.05 |
Browse Plan Formulary |
McLaren Advantage Diamond + (HMO)
|
$160.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 4 |
Specialty Tier |
29% | n/a | P | $4,111.17 |
Browse Plan Formulary |
McLaren Advantage Diamond + (HMO)
|
$160.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 4 |
Specialty Tier |
29% | n/a | P | $4,087.37 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$181.00 |
$105 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
30% | n/a | Q:4 /28Days | $4,066.93 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$181.00 |
$105 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
30% | n/a | Q:4 /28Days | $4,066.93 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$181.00 |
$105 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
30% | n/a | Q:4 /28Days | $3,887.39 |
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 |
Medicare Plus Blue PPO Signature (PPO)
|
$181.00 |
$105 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
30% | n/a | Q:4 /28Days | $3,887.39 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$181.00 |
$105 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
30% | n/a | Q:4 /28Days | $4,066.93 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$182.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | None | $4,068.05 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$182.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | None | $4,068.05 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$182.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | None | $4,068.05 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$182.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | None | $4,068.05 |
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 |
PriorityMedicare Select (PPO)
|
$182.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | None | $3,962.50 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$303.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:4 /28Days | $3,887.39 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$303.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:4 /28Days | $4,066.65 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$303.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:4 /28Days | $4,066.65 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$303.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:4 /28Days | $3,887.39 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$303.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:4 /28Days | $4,066.65 |
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 |
Medicare Plus Blue PPO Assure (PPO)
|
$314.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | Q:4 /28Days | $3,887.39 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$314.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | Q:4 /28Days | $3,887.39 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$314.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | Q:4 /28Days | $4,066.93 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$314.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | Q:4 /28Days | $4,066.93 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$314.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | Q:4 /28Days | $4,066.93 |
Browse Plan Formulary |