ABILIFY MAINTENA ER 300 MG SYR (NDC: 59148004580)
2016 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 |
to be determined |
5 |
Specialty Tier |
33% | 33% | None | $1,395.60 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | None | $1,395.60 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | None | $1,395.60 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | None | $1,395.60 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None | $1,416.55 |
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 |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None | $1,416.55 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $1,405.04 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $1,405.04 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $1,405.04 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $1,405.04 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
to be determined |
6 |
Specialty Tier |
33% | n/a | P | $1,371.17 |
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 |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
to be determined |
6 |
Specialty Tier |
33% | n/a | P | $1,371.17 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 |
to be determined |
6 |
Tier 6 |
33% | n/a | P | $1,371.17 |
Browse Plan Formulary |
Bridges Drug Savings (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | Q:1 /28Days | $1,383.49 |
Browse Plan Formulary |
Bridges Drug Savings (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | Q:1 /28Days | $1,383.49 |
Browse Plan Formulary |
Care1st AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | P | $1,398.48 |
Browse Plan Formulary |
Care1st AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | P | $1,398.48 |
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 |
Care1st Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | P | $1,398.48 |
Browse Plan Formulary |
Care1st Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | P | $1,398.48 |
Browse Plan Formulary |
CareMore Breathe (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | Q:1 /28Days | $1,407.75 |
Browse Plan Formulary |
CareMore Breathe (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | Q:1 /28Days | $1,407.75 |
Browse Plan Formulary |
CareMore Cal MediConnect Medicare-Medicaid Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | Q:1 /28Days | $1,407.75 |
Browse Plan Formulary |
CareMore Cal MediConnect Medicare-Medicaid Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
0% | 0% | Q:1 /28Days | $1,407.75 |
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 |
$360 |
to be determined |
5 |
Tier 5 |
25% | n/a | Q:1 /28Days | $1,407.75 |
Browse Plan Formulary |
CareMore Connect (HMO SNP)
|
$0.00 |
$360 |
to be determined |
5 |
Tier 5 |
25% | n/a | Q:1 /28Days | $1,407.75 |
Browse Plan Formulary |
CareMore ESRD (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | Q:1 /28Days | $1,407.75 |
Browse Plan Formulary |
CareMore ESRD (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | Q:1 /28Days | $1,407.75 |
Browse Plan Formulary |
CareMore Heart (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | Q:1 /28Days | $1,407.75 |
Browse Plan Formulary |
CareMore Heart (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | Q:1 /28Days | $1,407.75 |
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 |
to be determined |
5 |
Tier 5 |
33% | n/a | Q:1 /28Days | $1,407.75 |
Browse Plan Formulary |
CareMore Reliance (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | Q:1 /28Days | $1,407.75 |
Browse Plan Formulary |
CareMore StartSmart Plus (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | Q:1 /28Days | $1,407.75 |
Browse Plan Formulary |
CareMore StartSmart Plus (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | Q:1 /28Days | $1,407.75 |
Browse Plan Formulary |
CareMore Touch (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | Q:1 /28Days | $1,407.75 |
Browse Plan Formulary |
CareMore Touch (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | Q:1 /28Days | $1,407.75 |
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 |
to be determined |
5 |
Tier 5 |
33% | n/a | Q:1 /28Days | $1,413.14 |
Browse Plan Formulary |
CareMore Value Plus (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | Q:1 /28Days | $1,413.14 |
Browse Plan Formulary |
Central Health Focus Plan (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $1,413.14 |
Browse Plan Formulary |
Central Health Focus Plan (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $1,413.14 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $1,413.14 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $1,413.14 |
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 |
Classic Care (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | Q:1 /28Days | $1,384.38 |
Browse Plan Formulary |
Classic Care (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | Q:1 /28Days | $1,384.38 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $1,477.80 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $1,477.80 |
Browse Plan Formulary |
Golden State Medicare Health Plan, Golden (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | None | $1,396.94 |
Browse Plan Formulary |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | None | $1,446.07 |
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 |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | None | $1,446.07 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | None | $1,460.61 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | None | $1,460.61 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | None | $1,460.61 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | None | $1,460.61 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | None | $1,460.61 |
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 Jade (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | None | $1,460.61 |
Browse Plan Formulary |
Healthy Heart Drug Savings (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | Q:1 /28Days | $1,384.38 |
Browse Plan Formulary |
Healthy Heart Drug Savings (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | Q:1 /28Days | $1,384.38 |
Browse Plan Formulary |
Hope Drug Savings (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | Q:1 /28Days | $1,384.38 |
Browse Plan Formulary |
Hope Drug Savings (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | Q:1 /28Days | $1,384.38 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | Q:2 /28Days | $1,384.63 |
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 H5619-021 (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | Q:2 /28Days | $1,384.63 |
Browse Plan Formulary |
In Control Drug Savings (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | Q:1 /28Days | $1,384.38 |
Browse Plan Formulary |
In Control Drug Savings (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | Q:1 /28Days | $1,384.38 |
Browse Plan Formulary |
Inter Valley Health Plan Service To Seniors (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P | $1,413.14 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$95.00 | $190.00 | None | $1,479.08 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$95.00 | $190.00 | None | $1,479.08 |
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 LA, Orange Co. (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $1,479.08 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $1,479.08 |
Browse Plan Formulary |
L.A Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | P | $1,399.79 |
Browse Plan Formulary |
L.A Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | P | $1,399.79 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | Q:1 /28Days | $1,441.18 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | Q:1 /28Days | $1,441.18 |
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 |
PHP (HMO SNP)
|
$0.00 |
$360 |
to be determined |
4 |
Specialty Tier |
25% | n/a | Q:1 /28Days | $1,398.53 |
Browse Plan Formulary |
PHP (HMO SNP)
|
$0.00 |
$360 |
to be determined |
4 |
Specialty Tier |
25% | n/a | Q:1 /28Days | $1,398.53 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | None | $1,407.53 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | None | $1,407.53 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | None | $1,407.53 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | None | $1,407.53 |
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 |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | None | $1,407.53 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | None | $1,407.53 |
Browse Plan Formulary |
Easy Choice Freedom Plan (HMO SNP)
|
$8.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | Q:1 /28Days | $1,477.80 |
Browse Plan Formulary |
Easy Choice Freedom Plan (HMO SNP)
|
$8.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | Q:1 /28Days | $1,477.80 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$12.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | Q:1 /28Days | $1,477.80 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$12.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | Q:1 /28Days | $1,477.80 |
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 |
Molina Medicare Options Plus (HMO SNP)
|
$18.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | Q:1 /28Days | $1,442.55 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$18.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | Q:1 /28Days | $1,442.55 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$20.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | None | $1,460.61 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$20.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | None | $1,460.61 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$20.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | None | $1,460.61 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$20.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | None | $1,460.61 |
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 Plus (HMO)
|
$22.00 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | Q:1 /28Days | $1,407.75 |
Browse Plan Formulary |
CareMore Connect Plus (HMO)
|
$22.00 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | Q:1 /28Days | $1,407.75 |
Browse Plan Formulary |
Humana Gold Plus H5619-037 (HMO)
|
$23.40 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | Q:2 /28Days | $1,384.63 |
Browse Plan Formulary |
Humana Gold Plus H5619-037 (HMO)
|
$23.40 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | Q:2 /28Days | $1,384.63 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$25.20 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None | $1,479.08 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$25.20 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None | $1,479.08 |
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 |
Aetna Medicare Select Plan (HMO)
|
$27.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None | $1,416.55 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$27.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | None | $1,416.55 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 3 (HMO)
|
$27.40 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $1,395.60 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 3 (HMO)
|
$27.40 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $1,395.60 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$31.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | Q:1 /28Days | $1,405.04 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$31.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | Q:1 /28Days | $1,405.04 |
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 - Dual Access (HMO SNP)
|
$31.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | 25% | Q:1 /28Days | $1,383.49 |
Browse Plan Formulary |
Bridges - Dual Access (HMO SNP)
|
$31.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | 25% | Q:1 /28Days | $1,383.49 |
Browse Plan Formulary |
Care1st TotalDual Plan (HMO SNP)
|
$31.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | 25% | P | $1,398.48 |
Browse Plan Formulary |
Care1st TotalDual Plan (HMO SNP)
|
$31.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | 25% | P | $1,398.48 |
Browse Plan Formulary |
Classic Choice for Medi-Medi (HMO)
|
$31.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | 25% | Q:1 /28Days | $1,384.38 |
Browse Plan Formulary |
Classic Choice for Medi-Medi (HMO)
|
$31.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | 25% | Q:1 /28Days | $1,384.38 |
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 |
Coordinated Choice Plan (HMO)
|
$31.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | 25% | P | $1,398.48 |
Browse Plan Formulary |
Coordinated Choice Plan (HMO)
|
$31.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | 25% | P | $1,398.48 |
Browse Plan Formulary |
Dual Coverage (HMO SNP)
|
$31.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | 25% | Q:1 /28Days | $1,384.38 |
Browse Plan Formulary |
Dual Coverage (HMO SNP)
|
$31.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | 25% | Q:1 /28Days | $1,384.38 |
Browse Plan Formulary |
Harmony - Dual Access (HMO SNP)
|
$31.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | 25% | Q:1 /28Days | $1,384.38 |
Browse Plan Formulary |
Harmony - Dual Access (HMO SNP)
|
$31.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | 25% | Q:1 /28Days | $1,384.38 |
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 Amber I (HMO SNP)
|
$31.00 |
$270 |
to be determined |
5 |
Specialty Tier |
27% | 27% | None | $1,446.07 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$31.00 |
$270 |
to be determined |
5 |
Specialty Tier |
27% | 27% | None | $1,446.07 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$31.00 |
$280 |
to be determined |
5 |
Specialty Tier |
26% | 26% | None | $1,446.07 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$31.00 |
$280 |
to be determined |
5 |
Specialty Tier |
26% | 26% | None | $1,446.07 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$31.00 |
$280 |
to be determined |
5 |
Specialty Tier |
26% | 26% | None | $1,446.07 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$31.00 |
$280 |
to be determined |
5 |
Specialty Tier |
26% | 26% | None | $1,446.07 |
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 |
Health Net Seniority Plus Sapphire (HMO)
|
$31.00 |
$290 |
to be determined |
5 |
Specialty Tier |
26% | 26% | None | $1,446.07 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$31.00 |
$290 |
to be determined |
5 |
Specialty Tier |
26% | 26% | None | $1,446.07 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$31.00 |
$290 |
to be determined |
5 |
Specialty Tier |
26% | 26% | None | $1,446.07 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$31.00 |
$290 |
to be determined |
5 |
Specialty Tier |
26% | 26% | None | $1,446.07 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$31.00 |
$310 |
to be determined |
5 |
Specialty Tier |
26% | 26% | None | $1,446.07 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$31.00 |
$310 |
to be determined |
5 |
Specialty Tier |
26% | 26% | None | $1,446.07 |
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 |
Healthy Heart - Dual Access (HMO SNP)
|
$31.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | 25% | Q:1 /28Days | $1,384.38 |
Browse Plan Formulary |
Healthy Heart - Dual Access (HMO SNP)
|
$31.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | 25% | Q:1 /28Days | $1,384.38 |
Browse Plan Formulary |
In Control - Dual Access (HMO SNP)
|
$31.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | 25% | Q:1 /28Days | $1,384.38 |
Browse Plan Formulary |
In Control - Dual Access (HMO SNP)
|
$31.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | 25% | Q:1 /28Days | $1,384.38 |
Browse Plan Formulary |
Central Health Advance Plan (HMO SNP)
|
$31.10 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $1,413.14 |
Browse Plan Formulary |
Central Health Advance Plan (HMO SNP)
|
$31.10 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | Q:1 /28Days | $1,413.14 |
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 |
Central Health Medi-Medi Plan (HMO SNP)
|
$31.10 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | Q:1 /28Days | $1,413.14 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO SNP)
|
$31.10 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | Q:1 /28Days | $1,413.14 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$31.10 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | Q:1 /28Days | $1,413.14 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$31.10 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | Q:1 /28Days | $1,413.14 |
Browse Plan Formulary |
SCAN Connections (HMO SNP)
|
$31.10 |
$360 |
to be determined |
5 |
Tier 5 |
$0.00 | $0.00 | None | $1,407.53 |
Browse Plan Formulary |
SCAN Connections (HMO SNP)
|
$31.10 |
$360 |
to be determined |
5 |
Tier 5 |
$0.00 | $0.00 | None | $1,407.53 |
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 |
SCAN Connections at Home (HMO SNP)
|
$31.10 |
$360 |
to be determined |
5 |
Tier 5 |
$0.00 | $0.00 | None | $1,407.53 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
|
$31.10 |
$360 |
to be determined |
5 |
Tier 5 |
$0.00 | $0.00 | None | $1,407.53 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$31.10 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $1,407.53 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$31.10 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $1,407.53 |
Browse Plan Formulary |
VillageHealth (HMO-POS SNP)
|
$31.10 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $1,407.53 |
Browse Plan Formulary |
VillageHealth (HMO-POS SNP)
|
$31.10 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $1,407.53 |
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 |
Humana Gold Plus H5619-022 (HMO)
|
$39.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | Q:2 /28Days | $1,384.63 |
Browse Plan Formulary |
Humana Gold Plus H5619-022 (HMO)
|
$39.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | Q:2 /28Days | $1,384.63 |
Browse Plan Formulary |