TIVICAY PD 5 MG TABLET FOR SUSPENSION (UNITS ) (NDC: 49702025537)
2022 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 Medicare Advantage Plan 1 (HMO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
28% | n/a | Q:180 /30Days | $430.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Walgreens (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | Q:180 /30Days | $429.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Explorer Plan (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $437.40 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $437.40 |
Browse Plan Formulary |
CCA Medicare Preferred (PPO)
|
$0.00 |
$195 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $504.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
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 |
CCA One Care (Medicare-Medicaid Plan)
|
$0.00 |
$0 | All Generics, All Brands | 3 |
Tier 3 |
0% | 0% | None | $472.20 |
Browse Plan Formulary |
Fallon Medicare Plus Orange HMO (HMO)
|
$0.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $74.00 | None | $414.60 |
Browse Plan Formulary |
Fallon Medicare Plus Orange HMO (HMO)
|
$0.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $74.00 | None | $414.60 |
Browse Plan Formulary |
Fallon Medicare Plus Orange HMO (HMO)
|
$0.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $74.00 | None | $414.60 |
Browse Plan Formulary |
Fallon Medicare Plus Orange HMO (HMO)
|
$0.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $74.00 | None | $414.60 |
Browse Plan Formulary |
Health New England Medicare Compass (PPO)
|
$0.00 |
$380 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
26% | n/a | None | $418.20 |
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 |
Health New England Medicare Value (HMO)
|
$0.00 |
$380 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
26% | n/a | None | $418.20 |
Browse Plan Formulary |
HumanaChoice H5216-138 (PPO)
|
$0.00 |
$275 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
28% | n/a | Q:180 /30Days | $418.20 |
Browse Plan Formulary |
HumanaChoice H5216-249 (PPO)
|
$0.00 |
$295 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
28% | n/a | Q:180 /30Days | $418.20 |
Browse Plan Formulary |
Medicare HMO Blue SaverRx (HMO)
|
$0.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
28% | n/a | None | $403.20 |
Browse Plan Formulary |
Medicare PPO Blue SaverRx (PPO)
|
$0.00 |
$175 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
30% | n/a | None | $403.20 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Saver Rx (HMO)
|
$0.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $434.40 |
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 Smart Saver Rx (HMO)
|
$0.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $434.40 |
Browse Plan Formulary |
UnitedHealthcare Connected® for One Care (Medicare-Medicaid Plan)
|
$0.00 |
$0 | All Generics, All Brands | 2 |
Tier 2 |
0% | 0% | Q:180 /30Days | $430.80 |
Browse Plan Formulary |
Wellcare Giveback Open (PPO)
|
$0.00 |
$350 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$37.00 | $74.00 | None | $433.20 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$35.00 | $70.00 | None | $433.20 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $74.00 | None | $433.20 |
Browse Plan Formulary |
HumanaChoice H5216-250 (PPO)
|
$20.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
28% | n/a | Q:180 /30Days | $418.20 |
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 |
Wellcare Assist Open (PPO)
|
$22.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $94.00 | None | $434.40 |
Browse Plan Formulary |
UnitedHealthcare Senior Care Options (HMO D-SNP)
|
$28.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
$0.00 | $0.00 | Q:180 /30Days | $430.80 |
Browse Plan Formulary |
UnitedHealthcare Senior Care Options NHC (HMO D-SNP)
|
$30.80 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
$0.00 | $0.00 | Q:180 /30Days | $430.80 |
Browse Plan Formulary |
AARP Medicare Advantage Choice (Regional PPO)
|
$35.90 |
$295 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
28% | n/a | Q:180 /30Days | $430.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Medicare HMO Blue ValueRx (HMO)
|
$36.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
27% | n/a | None | $403.20 |
Browse Plan Formulary |
Medicare HMO Blue ValueRx (HMO)
|
$36.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
27% | n/a | None | $403.20 |
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 D-SNP)
|
$36.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $400.80 |
Browse Plan Formulary |
CCA Medicare Value (PPO)
|
$36.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $504.60 |
Browse Plan Formulary |
CCA Senior Care Options (HMO D-SNP)
|
$36.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | 25% | None | $472.20 |
Browse Plan Formulary |
NaviCare (HMO D-SNP)
|
$36.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $414.60 |
Browse Plan Formulary |
Senior Whole Health (HMO D-SNP)
|
$36.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $426.60 |
Browse Plan Formulary |
Senior Whole Health NHC (HMO D-SNP)
|
$36.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $426.60 |
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 |
Tufts Health Plan Senior Care Options (HMO D-SNP)
|
$36.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $421.80 |
Browse Plan Formulary |
Fallon Medicare Plus Super Saver HMO (HMO)
|
$42.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $414.60 |
Browse Plan Formulary |
Fallon Medicare Plus Super Saver HMO (HMO)
|
$42.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $414.60 |
Browse Plan Formulary |
Fallon Medicare Plus Super Saver HMO (HMO)
|
$42.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $414.60 |
Browse Plan Formulary |
Fallon Medicare Plus Super Saver HMO (HMO)
|
$42.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $414.60 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$45.00 |
$225 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $434.40 |
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 Basic Rx (HMO)
|
$45.00 |
$225 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $434.40 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$45.00 |
$225 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $434.40 |
Browse Plan Formulary |
Health New England Medicare Choice (HMO)
|
$46.00 |
$350 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
26% | n/a | None | $418.20 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 2 (HMO)
|
$49.00 |
$225 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
29% | n/a | Q:180 /30Days | $430.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Premium Enhanced Open (PPO)
|
$60.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$35.00 | $70.00 | None | $433.20 |
Browse Plan Formulary |
Fallon Medicare Plus Green HMO (HMO)
|
$68.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $74.00 | None | $414.60 |
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 |
Fallon Medicare Plus Green HMO (HMO)
|
$68.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $74.00 | None | $414.60 |
Browse Plan Formulary |
Fallon Medicare Plus Green HMO (HMO)
|
$68.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $74.00 | None | $414.60 |
Browse Plan Formulary |
Fallon Medicare Plus Green HMO (HMO)
|
$68.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $74.00 | None | $414.60 |
Browse Plan Formulary |
Medicare PPO Blue ValueRx (PPO)
|
$76.00 |
$290 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
28% | n/a | None | $403.20 |
Browse Plan Formulary |
Medicare PPO Blue ValueRx (PPO)
|
$76.00 |
$290 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
28% | n/a | None | $403.20 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$89.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $434.40 |
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 Value Rx (HMO)
|
$89.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $434.40 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$89.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $434.40 |
Browse Plan Formulary |
Medicare HMO Blue FlexRx (HMO-POS)
|
$96.00 |
$260 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
28% | n/a | None | $403.20 |
Browse Plan Formulary |
Medicare HMO Blue FlexRx (HMO-POS)
|
$96.00 |
$260 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
28% | n/a | None | $403.20 |
Browse Plan Formulary |
Health New England Medicare Compass Premier (PPO)
|
$99.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
28% | n/a | None | $418.20 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$109.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $421.80 |
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 |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$109.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $421.80 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$109.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $421.80 |
Browse Plan Formulary |
Health New England Medicare Plus (HMO)
|
$113.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
28% | n/a | None | $418.20 |
Browse Plan Formulary |
Fallon Medicare Plus Blue HMO (HMO)
|
$117.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $74.00 | None | $414.60 |
Browse Plan Formulary |
Fallon Medicare Plus Blue HMO (HMO)
|
$117.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $74.00 | None | $414.60 |
Browse Plan Formulary |
Fallon Medicare Plus Blue HMO (HMO)
|
$117.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $74.00 | None | $414.60 |
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 |
Fallon Medicare Plus Blue HMO (HMO)
|
$117.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $74.00 | None | $414.60 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$129.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$80.00 | $240.00 | None | $421.80 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$129.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$80.00 | $240.00 | None | $421.80 |
Browse Plan Formulary |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$129.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$80.00 | $240.00 | None | $421.80 |
Browse Plan Formulary |
Health New England Medicare Premium (HMO)
|
$170.00 |
$250 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
28% | n/a | None | $418.20 |
Browse Plan Formulary |
Medicare PPO Blue PlusRx (PPO)
|
$264.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
29% | n/a | None | $403.20 |
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 PlusRx (HMO)
|
$268.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
29% | n/a | None | $403.20 |
Browse Plan Formulary |