SUSTIVA 200MG CAPSULE (90 BOT) (NDC: 00056047492)
2014 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 |
AARP MedicareComplete SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 | Some Generics | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $526.67 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 | Some Generics | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $526.67 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 | Few Generics | 3 |
Non-Preferred Brand |
50% | 50% | None | $526.00 |
Browse Plan Formulary |
Blue Cross Senior Secure Plan I (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $120.00 | None | $528.10 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 | Many Generics | 3 |
Preferred Brand |
$45.00 | $90.00 | None | $524.34 |
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 |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 | Many Generics | 2 |
Preferred Brand |
$35.00 | $70.00 | None | $524.34 |
Browse Plan Formulary |
Brand New Day Dementia with Enhanced Drug Benefits (HMO SNP)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $538.03 |
Browse Plan Formulary |
Brand New Day Diabetes with Enhanced Drug Benefits (HMO SNP)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $538.03 |
Browse Plan Formulary |
Brand New Day Enhanced Drug Savings for So Cal (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $537.11 |
Browse Plan Formulary |
Care1st AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 | Many Generics | 3 |
Preferred Brand |
$30.00 | $60.00 | None | $529.83 |
Browse Plan Formulary |
Care1st AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 | Many Generics | 3 |
Preferred Brand |
$35.00 | $70.00 | None | $528.94 |
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 |
CareMore Breathe (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 3 |
Preferred Brand |
$30.00 | $75.00 | None | $543.17 |
Browse Plan Formulary |
CareMore Connect (HMO SNP)
|
$0.00 |
$310 | Many Generics | 3 |
Preferred Brand |
25% | 25% | None | $543.16 |
Browse Plan Formulary |
CareMore ESRD (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 3 |
Preferred Brand |
$30.00 | $75.00 | None | $543.17 |
Browse Plan Formulary |
CareMore Heart (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 3 |
Preferred Brand |
$30.00 | $75.00 | None | $543.17 |
Browse Plan Formulary |
CareMore Reliance (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 3 |
Preferred Brand |
$30.00 | $75.00 | None | $543.17 |
Browse Plan Formulary |
CareMore StartSmart Plus (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $112.50 | None | $543.17 |
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 |
CareMore Touch (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 3 |
Preferred Brand |
$30.00 | $75.00 | None | $543.17 |
Browse Plan Formulary |
CareMore Value Plus (HMO)
|
$0.00 |
$0 | Many Generics, Few Brands | 3 |
Preferred Brand |
$30.00 | $75.00 | None | $540.12 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 | All Generics | 4 |
Non-Preferred Brand |
$50.00 | $100.00 | None | $540.12 |
Browse Plan Formulary |
Citizens Choice Healthplan (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$75.00 | $150.00 | None | $527.40 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $528.51 |
Browse Plan Formulary |
Golden State Medicare Health Plan, Golden (HMO)
|
$0.00 |
$0 | Many Generics, Few Brands | 2 |
Preferred Brand |
$40.00 | $80.00 | None | $527.15 |
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 Net Gold Select (HMO)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$95.00 | $238.00 | None | $522.26 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$95.00 | $238.00 | None | $522.73 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $522.26 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $522.73 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $522.66 |
Browse Plan Formulary |
Health Net Seniority Plus Ruby (HMO)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $522.26 |
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 Net Seniority Plus Ruby (HMO)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $522.73 |
Browse Plan Formulary |
Heart First (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $528.10 |
Browse Plan Formulary |
Humana Gold Plus H0108-011 (HMO)
|
$0.00 |
$0 | Some Generics, Few Brands | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:120 /30Days | $516.24 |
Browse Plan Formulary |
Inter Valley Health Plan Service To Seniors (HMO)
|
$0.00 |
$0 | Some Generics | 3 |
Preferred Brand |
$39.00 | $78.00 | None | $540.12 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 | All Generics, Few Brands | 3 |
Preferred Brand |
$45.00 | $90.00 | None | $565.72 |
Browse Plan Formulary |
PHP (HMO SNP)
|
$0.00 |
$310 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
25% | n/a | None | $530.57 |
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 |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $528.10 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$85.00 | $170.00 | None | $526.86 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$85.00 | $170.00 | None | $526.97 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$4.00 |
$0 | to be determined | 3 |
Preferred Brand |
$45.00 | $90.00 | None | $566.07 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$14.40 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $90.00 | None | $566.07 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 3 (HMO)
|
$16.20 |
$310 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $527.15 |
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 |
Care1st TotalDual Plan (HMO SNP)
|
$20.70 |
$310 | Few Generics | 3 |
Preferred Brand |
25% | 25% | None | $528.95 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$21.60 |
$310 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$45.00 | $135.00 | None | $524.36 |
Browse Plan Formulary |
SCAN Connections (HMO SNP)
|
$24.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
n/a | n/a | None | $526.86 |
Browse Plan Formulary |
Easy Choice Freedom Plan (HMO SNP)
|
$24.40 |
$310 | Call plan for details | 4 |
Non-Preferred Brand |
25% | 17% | None | $528.95 |
Browse Plan Formulary |
Coordinated Choice Plan (HMO)
|
$26.30 |
$310 | Few Generics | 3 |
Preferred Brand |
25% | 25% | None | $530.54 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$28.00 |
$310 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $525.65 |
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 |
Brand New Day Dementia with Extra Care (HMO SNP)
|
$28.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $538.03 |
Browse Plan Formulary |
Brand New Day Diabetes with Extra Care (HMO SNP)
|
$28.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $538.03 |
Browse Plan Formulary |
Brand New Day Dual Coverage (HMO SNP)
|
$28.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | None | $538.03 |
Browse Plan Formulary |
Brand New Day Extra Care (HMO)
|
$28.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $538.03 |
Browse Plan Formulary |
Brand New Day for Mental Illness (HMO SNP)
|
$28.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $538.03 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO SNP)
|
$28.10 |
$310 | Many Generics | 4 |
Non-Preferred Brand |
25% | 25% | None | $540.12 |
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 |
Central Health Premier Plan (HMO)
|
$28.10 |
$310 | Many Generics | 4 |
Non-Preferred Brand |
25% | 25% | None | $540.12 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$28.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $522.66 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$28.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $522.52 |
Browse Plan Formulary |
L.A. Care Health Plan Medicare Advantage (HMO SNP)
|
$28.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
n/a | n/a | None | $538.07 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
|
$28.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
n/a | n/a | None | $526.86 |
Browse Plan Formulary |
VillageHealth (HMO SNP)
|
$28.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $528.10 |
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 |
Inter Valley Health Plan Total Fit (HMO)
|
$30.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $135.00 | None | $540.12 |
Browse Plan Formulary |
Anthem Medicare Preferred Standard (PPO)
|
$80.00 |
$149 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $120.00 | None | $526.86 |
Browse Plan Formulary |