PLEGRIDY 125 MCG/0.5 ML SYRING (.5 ML ) (NDC: 64406001501)
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 | $6,450.96 |
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 | $6,450.96 |
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 | $6,349.17 |
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 | $6,349.17 |
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 | $6,450.96 |
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 | S Q:1 /28Days | $6,449.85 |
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 | S Q:1 /28Days | $6,449.85 |
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 | S Q:1 /28Days | $6,449.85 |
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 | S Q:1 /28Days | $6,294.58 |
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 | S Q:1 /28Days | $6,449.85 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | n/a | S Q:1 /28Days | $6,449.85 |
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 | S Q:1 /28Days | $6,449.85 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | n/a | S Q:1 /28Days | $6,449.85 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | n/a | S Q:1 /28Days | $6,449.85 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | n/a | S Q:1 /28Days | $6,294.58 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$25.50 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | n/a | P | $6,452.04 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$25.50 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | n/a | P | $6,349.17 |
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)
|
$25.50 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | n/a | P | $6,349.17 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$25.50 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | n/a | P | $6,452.04 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$25.50 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | n/a | P | $6,452.04 |
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 | S Q:1 /28Days | $6,294.56 |
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 Q:1 /28Days | $6,445.58 |
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 Q:1 /28Days | $6,445.58 |
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 |
Medicare Plus Blue PPO Vitality (PPO)
|
$88.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | n/a | P | $6,452.04 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$88.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | n/a | P | $6,452.04 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$88.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | n/a | P | $6,349.17 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$88.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | n/a | P | $6,452.04 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$88.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | n/a | P | $6,349.17 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | S Q:1 /28Days | $6,446.86 |
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 Merit (PPO)
|
$95.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | S Q:1 /28Days | $6,446.86 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | S Q:1 /28Days | $6,446.86 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | S Q:1 /28Days | $6,446.86 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | S Q:1 /28Days | $6,294.56 |
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 Q:1 /28Days | $6,445.58 |
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 Q:1 /28Days | $6,445.58 |
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 |
PriorityMedicare (HMO-POS)
|
$145.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | S Q:1 /28Days | $6,294.56 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$147.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $6,349.17 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$147.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $6,450.96 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$147.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $6,450.96 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$147.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $6,450.96 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$147.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $6,349.17 |
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)
|
$160.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Specialty Tier |
29% | n/a | P Q:1 /28Days | $6,445.58 |
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 Q:1 /28Days | $6,445.58 |
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 | P | $6,349.17 |
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 | P | $6,452.04 |
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 | P | $6,452.04 |
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 | P | $6,452.04 |
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 | P | $6,349.17 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$201.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | S Q:1 /28Days | $6,446.86 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$201.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | S Q:1 /28Days | $6,294.56 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$201.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | S Q:1 /28Days | $6,446.86 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$201.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | S Q:1 /28Days | $6,446.86 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$201.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | S Q:1 /28Days | $6,446.86 |
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)
|
$271.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $6,452.04 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$271.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $6,452.04 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$271.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $6,349.17 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$271.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $6,349.17 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$271.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $6,452.04 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$308.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $6,450.96 |
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 |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$308.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $6,450.96 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$308.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $6,450.96 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$308.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $6,349.17 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$308.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P | $6,349.17 |
Browse Plan Formulary |