SIMPONI GOLIMUMAB INJECTION 50MG/0.5ML 1 50 MG SINGLE DOSE SYR SYR (1 50 MG SINGLE DOSE SYR SYR) (NDC: 57894007001)
2019 Medicare Prescription Drug Plan (MAPD) Information
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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 |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,804.58 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,668.97 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,651.66 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,834.05 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
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 |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,759.39 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,759.39 |
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 |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,759.39 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
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 |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,748.57 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,748.57 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,748.57 |
Browse Plan Formulary |
UPMC for Life HMO Deductible with Rx (HMO)
|
$22.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,714.53 |
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 |
Community Blue Medicare PPO Signature (PPO)
|
$23.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,775.73 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$23.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,668.97 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$23.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,651.66 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$23.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,834.05 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$25.90 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
5 |
All Formulary Drugs |
$0.00 | $0.00 | P | $5,165.58 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete ONE (HMO SNP)
|
$26.70 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
5 |
All Formulary Drugs |
$0.00 | $0.00 | P | $5,165.58 |
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 |
Geisinger Gold Secure Rx (HMO SNP)
|
$37.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
All Formulary Drugs |
15% | 15% | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
UPMC for Life Dual (HMO SNP)
|
$37.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:1 /28Days | $4,711.65 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,730.18 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
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 |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,730.18 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,730.18 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
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 |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,748.57 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,748.57 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,748.57 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
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 |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Freedom Blue PPO ValueRx (PPO)
|
$71.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,678.32 |
Browse Plan Formulary |
UPMC for Life HMO Rx (HMO)
|
$81.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,714.53 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$117.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$117.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,748.57 |
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 |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$117.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$117.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$117.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$117.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$117.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$117.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,748.57 |
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 |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$117.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,748.57 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$183.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,730.18 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$183.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,730.18 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$183.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$183.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,730.18 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$183.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
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 |
Geisinger Gold Classic Advantage Rx (HMO)
|
$183.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$183.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$183.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$183.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,622.88 |
Browse Plan Formulary |
Freedom Blue PPO Standard (PPO)
|
$186.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,678.32 |
Browse Plan Formulary |
Freedom Blue PPO Deluxe (PPO)
|
$289.50 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,678.32 |
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 |
UPMC for Life HMO Rx Enhanced (HMO)
|
$290.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $4,717.09 |
Browse Plan Formulary |