ATROPINE 0.1MG/ML SYRINGE (10 X 5 ML SYR) (NDC: 00409962905)
2015 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 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $22.67 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $22.67 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $22.67 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $22.67 |
Browse Plan Formulary |
Anthem Select Advantage (HMO)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $30.14 |
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 |
Anthem Select Advantage (HMO)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $30.14 |
Browse Plan Formulary |
Blue Cross Senior Secure Plan I (HMO)
|
$0.00 |
$50 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $30.14 |
Browse Plan Formulary |
Blue Cross Senior Secure Plan I (HMO)
|
$0.00 |
$50 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $30.14 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Injectable Drugs |
25% | 25% | None | $82.71 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Injectable Drugs |
25% | 25% | None | $82.71 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Injectable Drugs |
25% | 25% | None | $82.71 |
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 |
Bridges Drug Savings (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$9.00 | $25.00 | None | $25.55 |
Browse Plan Formulary |
Bridges Drug Savings (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$9.00 | $25.00 | None | $25.55 |
Browse Plan Formulary |
CareMore Breathe (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.50 | $18.75 | P | $18.64 |
Browse Plan Formulary |
CareMore Breathe (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.50 | $18.75 | P | $18.64 |
Browse Plan Formulary |
CareMore Cal MediConnect Medicare-Medicaid Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Brand Drugs |
0% | 0% | P | $18.64 |
Browse Plan Formulary |
CareMore Cal MediConnect Medicare-Medicaid Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Brand Drugs |
0% | 0% | P | $18.64 |
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 Connect (HMO SNP)
|
$0.00 |
$320* |
Yes, but No Gap Coverage for this drug. |
2* |
Non-Preferred Generic |
$0.00 | $0.00 | P | $18.64 |
Browse Plan Formulary |
CareMore Connect (HMO SNP)
|
$0.00 |
$320* |
Yes, but No Gap Coverage for this drug. |
2* |
Non-Preferred Generic |
$0.00 | $0.00 | P | $18.64 |
Browse Plan Formulary |
CareMore ESRD (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.50 | $18.75 | P | $18.64 |
Browse Plan Formulary |
CareMore ESRD (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.50 | $18.75 | P | $18.64 |
Browse Plan Formulary |
CareMore Heart (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.50 | $18.75 | P | $18.64 |
Browse Plan Formulary |
CareMore Heart (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.50 | $18.75 | P | $18.64 |
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 Reliance (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.50 | $18.75 | P | $18.64 |
Browse Plan Formulary |
CareMore Reliance (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.50 | $18.75 | P | $18.64 |
Browse Plan Formulary |
CareMore StartSmart Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$12.50 | $31.25 | P | $18.64 |
Browse Plan Formulary |
CareMore StartSmart Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$12.50 | $31.25 | P | $18.64 |
Browse Plan Formulary |
CareMore Touch (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.50 | $18.75 | P | $18.64 |
Browse Plan Formulary |
CareMore Touch (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.50 | $18.75 | P | $18.64 |
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 Value Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.50 | $18.75 | P | $18.64 |
Browse Plan Formulary |
CareMore Value Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.50 | $18.75 | P | $18.64 |
Browse Plan Formulary |
Central Health Focus Plan (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$50.00 | $100.00 | P | $18.64 |
Browse Plan Formulary |
Central Health Focus Plan (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$50.00 | $100.00 | P | $18.64 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO SNP)
|
$0.00 |
$320 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
25% | 25% | P | $18.64 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$50.00 | $100.00 | P | $18.64 |
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 Medicare Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$50.00 | $100.00 | P | $18.64 |
Browse Plan Formulary |
Citizens Choice Health Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None | $23.06 |
Browse Plan Formulary |
Citizens Choice Health Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None | $23.06 |
Browse Plan Formulary |
Classic Care (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$9.00 | $25.00 | None | $25.55 |
Browse Plan Formulary |
Classic Care (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$9.00 | $25.00 | None | $25.55 |
Browse Plan Formulary |
Dual Coverage (HMO SNP)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
25% | 25% | None | $25.55 |
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 |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $24.74 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $24.74 |
Browse Plan Formulary |
Easy Choice Freedom Plan (HMO SNP)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$29.00 | $72.50 | None | $24.74 |
Browse Plan Formulary |
Healthy Heart Drug Savings (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$9.00 | $25.00 | None | $25.55 |
Browse Plan Formulary |
Healthy Heart Drug Savings (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$9.00 | $25.00 | None | $25.55 |
Browse Plan Formulary |
Heart First (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.00 | $14.00 | None | $30.14 |
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 |
Heart First (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.00 | $14.00 | None | $30.14 |
Browse Plan Formulary |
Hope Drug Savings (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$9.00 | $25.00 | None | $25.55 |
Browse Plan Formulary |
Hope Drug Savings (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$9.00 | $25.00 | None | $25.55 |
Browse Plan Formulary |
Humana Gold Plus H0108-011 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$10.00 | $0.00 | None | $27.82 |
Browse Plan Formulary |
In Control Drug Savings (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$9.00 | $25.00 | None | $25.55 |
Browse Plan Formulary |
In Control Drug Savings (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$9.00 | $25.00 | None | $25.55 |
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 |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$12.00 | $24.00 | None | $22.07 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$12.00 | $24.00 | None | $22.07 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $36.85 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $36.85 |
Browse Plan Formulary |
L.A Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic Drugs |
0% | 0% | P | $25.11 |
Browse Plan Formulary |
L.A Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic Drugs |
0% | 0% | P | $25.11 |
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 |
Platinum Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None | $23.06 |
Browse Plan Formulary |
Platinum Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None | $23.06 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.00 | $14.00 | None | $30.14 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$7.00 | $14.00 | None | $30.14 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $30.14 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $30.14 |
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 Connections (HMO SNP)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $30.14 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $30.14 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $30.14 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $30.14 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None | $22.07 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$15.30 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None | $22.07 |
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 |
Humana Gold Plus H0108-050 (HMO)
|
$22.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None | $27.82 |
Browse Plan Formulary |
Easy Choice Freedom Plan (HMO SNP)
|
$23.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$29.00 | $72.50 | None | $24.74 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$23.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$29.00 | $72.50 | None | $24.74 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$23.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$29.00 | $72.50 | None | $24.74 |
Browse Plan Formulary |
Humana Gold Plus H0108-047 (HMO)
|
$28.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None | $27.82 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 3 (HMO)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $22.67 |
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 |
AARP MedicareComplete SecureHorizons Plan 3 (HMO)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $22.67 |
Browse Plan Formulary |
Bridges Extra Care (HMO SNP)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
25% | 25% | None | $25.55 |
Browse Plan Formulary |
Bridges Extra Care (HMO SNP)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
25% | 25% | None | $25.55 |
Browse Plan Formulary |
CalPlus Plan (HMO)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $23.06 |
Browse Plan Formulary |
CalPlus Plan (HMO)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $23.06 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO SNP)
|
$28.80 |
$320 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
25% | 25% | P | $18.64 |
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)
|
$28.80 |
$320 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
25% | 25% | P | $18.64 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$28.80 |
$320 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
25% | 25% | P | $18.64 |
Browse Plan Formulary |
Dual Coverage (HMO SNP)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
25% | 25% | None | $25.55 |
Browse Plan Formulary |
Harmony (HMO SNP)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $25.55 |
Browse Plan Formulary |
Harmony (HMO SNP)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $25.55 |
Browse Plan Formulary |
Healthy Heart Extra Care (HMO SNP)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
25% | 25% | None | $25.55 |
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 |
Healthy Heart Extra Care (HMO SNP)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
25% | 25% | None | $25.55 |
Browse Plan Formulary |
In Control Extra Care (HMO SNP)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
25% | 25% | None | $25.55 |
Browse Plan Formulary |
In Control Extra Care (HMO SNP)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
25% | 25% | None | $25.55 |
Browse Plan Formulary |
SCAN Connections (HMO SNP)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $30.14 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $30.14 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $30.14 |
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 Plus (HMO)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $30.14 |
Browse Plan Formulary |
VillageHealth (HMO SNP)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $30.14 |
Browse Plan Formulary |
VillageHealth (HMO SNP)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $30.14 |
Browse Plan Formulary |