TIVICAY 10 MG TABLET (NDC: 49702022613)
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 |
AARP MedicareComplete Plan 1 (HMO)
|
$0.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:60 /30Days | $372.86 |
Browse Plan Formulary |
Aetna Medicare Freedom Plan (PPO)
|
$0.00 |
$195 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $136.00 | None | $368.48 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$195 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $136.00 | None | $368.48 |
Browse Plan Formulary |
Commonwealth Care Alliance (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Non-Preferred Brand Drugs |
0% | 0% | None | $355.39 |
Browse Plan Formulary |
Fallon Senior Plan Flex Enhanced Rx (HMO)
|
$0.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$86.00 | $172.00 | None | $378.00 |
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 |
Fallon Senior Plan Flex Enhanced Rx (HMO)
|
$0.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$86.00 | $172.00 | None | $378.00 |
Browse Plan Formulary |
Fallon Senior Plan Flex Enhanced Rx (HMO)
|
$0.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$86.00 | $172.00 | None | $359.39 |
Browse Plan Formulary |
Fallon Senior Plan Flex Enhanced Rx (HMO)
|
$0.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$86.00 | $172.00 | None | $359.39 |
Browse Plan Formulary |
Harvard Pilgrim Stride Basic Rx (HMO)
|
$0.00 |
$415 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:60 /30Days | $338.56 |
Browse Plan Formulary |
Medicare HMO Blue SaverRx (HMO)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $349.71 |
Browse Plan Formulary |
Medicare PPO Blue SaverRx (PPO)
|
$0.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $349.71 |
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 |
Tufts Medicare Preferred HMO Saver Rx (HMO)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $347.48 |
Browse Plan Formulary |
AARP MedicareComplete Choice (Regional PPO)
|
$21.40 |
$295 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $362.15 |
Browse Plan Formulary |
Fallon Senior Plan Super Saver Rx (HMO)
|
$22.00 |
$415 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $378.00 |
Browse Plan Formulary |
Fallon Senior Plan Super Saver Rx (HMO)
|
$22.00 |
$415 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $378.00 |
Browse Plan Formulary |
Fallon Senior Plan Super Saver Rx (HMO)
|
$22.00 |
$415 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $378.00 |
Browse Plan Formulary |
Fallon Senior Plan Super Saver Rx (HMO)
|
$22.00 |
$415 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $354.17 |
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 |
Fallon Senior Plan Super Saver Rx (HMO)
|
$22.00 |
$415 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $359.39 |
Browse Plan Formulary |
Fallon Senior Plan Super Saver Rx (HMO)
|
$22.00 |
$415 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $359.39 |
Browse Plan Formulary |
UnitedHealthcare Senior Care Options (HMO SNP)
|
$23.10 |
$415 | No additional gap coverage, only the Donut Hole Discount | 4 |
All Formulary Drugs |
$0.00 | $0.00 | Q:60 /30Days | $359.17 |
Browse Plan Formulary |
Erickson Advantage Guardian (HMO-POS SNP)
|
$33.10 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$70.00 | $200.00 | Q:60 /30Days | $372.84 |
Browse Plan Formulary |
Medicare HMO Blue ValueRx (HMO)
|
$36.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $349.71 |
Browse Plan Formulary |
Medicare HMO Blue ValueRx (HMO)
|
$36.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $350.59 |
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 |
BMC HealthNet Plan Senior Care Options (HMO SNP)
|
$36.20 |
$415 | No additional gap coverage, only the Donut Hole Discount | 1 |
All Formulary Drugs |
$0.00 | $0.00 | Q:60 /30Days | $356.79 |
Browse Plan Formulary |
NaviCare (HMO SNP)
|
$36.20 |
$415 | No additional gap coverage, only the Donut Hole Discount | 1 |
All Formulary Drugs |
$0.00 | $0.00 | None | $352.74 |
Browse Plan Formulary |
Senior Care Options Program (HMO SNP)
|
$36.20 |
$415 | No additional gap coverage, only the Donut Hole Discount | 1 |
All Formulary Drugs |
$0.00 | $0.00 | None | $355.39 |
Browse Plan Formulary |
Senior Whole Health (HMO SNP)
|
$36.20 |
$415 | No additional gap coverage, only the Donut Hole Discount | 1 |
All Formulary Drugs |
15% | 15% | None | $349.71 |
Browse Plan Formulary |
Senior Whole Health NHC (HMO SNP)
|
$36.20 |
$415 | No additional gap coverage, only the Donut Hole Discount | 1 |
All Formulary Drugs |
15% | 15% | None | $349.71 |
Browse Plan Formulary |
Tufts Health Plan Senior Care Options (HMO SNP)
|
$36.20 |
$415 | No additional gap coverage, only the Donut Hole Discount | 4 |
All Formulary Drugs |
$0.00 | $0.00 | None | $347.48 |
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 Nursing Home Plan 1 (PPO SNP)
|
$36.20 |
$415 | No additional gap coverage, only the Donut Hole Discount | 4 |
All Formulary Drugs |
25% | 25% | Q:60 /30Days | $359.17 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 2 (PPO SNP)
|
$36.20 |
$415 | No additional gap coverage, only the Donut Hole Discount | 4 |
All Formulary Drugs |
25% | 25% | Q:60 /30Days | $359.17 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$40.00 |
$350 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $374.91 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$40.00 |
$350 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $347.48 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$40.00 |
$350 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $347.48 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$42.00 |
$225 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:60 /30Days | $372.86 |
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 |
Erickson Advantage Freedom (HMO-POS)
|
$48.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$85.00 | $245.00 | Q:60 /30Days | $372.84 |
Browse Plan Formulary |
Aetna Medicare Freedom Complete (PPO)
|
$57.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $136.00 | None | $368.48 |
Browse Plan Formulary |
Harvard Pilgrim Stride Value Rx (HMO)
|
$67.00 |
$350 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:60 /30Days | $338.56 |
Browse Plan Formulary |
Harvard Pilgrim Stride Value Rx (HMO)
|
$67.00 |
$350 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:60 /30Days | $354.30 |
Browse Plan Formulary |
Fallon Senior Plan Saver Enhanced Rx (HMO)
|
$72.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$86.00 | $172.00 | None | $378.00 |
Browse Plan Formulary |
Fallon Senior Plan Saver Enhanced Rx (HMO)
|
$72.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$86.00 | $172.00 | None | $378.00 |
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 |
Fallon Senior Plan Saver Enhanced Rx (HMO)
|
$72.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$86.00 | $172.00 | None | $354.17 |
Browse Plan Formulary |
Fallon Senior Plan Saver Enhanced Rx (HMO)
|
$72.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$86.00 | $172.00 | None | $359.39 |
Browse Plan Formulary |
Fallon Senior Plan Saver Enhanced Rx (HMO)
|
$72.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$86.00 | $172.00 | None | $359.39 |
Browse Plan Formulary |
AARP MedicareComplete Plan 3 (HMO)
|
$76.00 |
$95 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:60 /30Days | $372.86 |
Browse Plan Formulary |
Medicare PPO Blue ValueRx (PPO)
|
$76.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $350.59 |
Browse Plan Formulary |
Medicare PPO Blue ValueRx (PPO)
|
$76.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $349.71 |
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 HMO Blue FlexRx (HMO-POS)
|
$96.00 |
$260 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $349.71 |
Browse Plan Formulary |
Medicare HMO Blue FlexRx (HMO-POS)
|
$96.00 |
$260 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $350.59 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$131.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $374.91 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$131.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $347.48 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$131.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $347.48 |
Browse Plan Formulary |
Harvard Pilgrim Stride Value Rx Plus (HMO)
|
$163.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:60 /30Days | $338.56 |
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 |
Harvard Pilgrim Stride Value Rx Plus (HMO)
|
$163.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$100.00 | $250.00 | Q:60 /30Days | $354.30 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$165.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $347.48 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$165.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $347.48 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$165.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $374.91 |
Browse Plan Formulary |
Fallon Senior Plan Plus Enhanced Rx (HMO)
|
$173.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$86.00 | $172.00 | None | $359.39 |
Browse Plan Formulary |
Fallon Senior Plan Plus Enhanced Rx (HMO)
|
$173.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$86.00 | $172.00 | None | $359.39 |
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 |
Fallon Senior Plan Plus Enhanced Rx (HMO)
|
$173.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$86.00 | $172.00 | None | $354.17 |
Browse Plan Formulary |
Fallon Senior Plan Plus Enhanced Rx (HMO)
|
$173.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$86.00 | $172.00 | None | $378.00 |
Browse Plan Formulary |
Fallon Senior Plan Plus Enhanced Rx (HMO)
|
$173.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$86.00 | $172.00 | None | $378.00 |
Browse Plan Formulary |
Erickson Advantage Champion (HMO-POS SNP)
|
$195.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$85.00 | $245.00 | Q:60 /30Days | $372.84 |
Browse Plan Formulary |
Erickson Advantage Signature with Drugs (HMO-POS)
|
$195.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$85.00 | $245.00 | Q:60 /30Days | $372.84 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$199.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$80.00 | $240.00 | None | $347.48 |
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 |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$199.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$80.00 | $240.00 | None | $347.48 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$199.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$80.00 | $240.00 | None | $374.91 |
Browse Plan Formulary |
Medicare PPO Blue PlusRx (PPO)
|
$262.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $349.71 |
Browse Plan Formulary |
Medicare HMO Blue PlusRx (HMO)
|
$292.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $349.71 |
Browse Plan Formulary |