AMIFOSTINE 50mg/mL 3 VIAL, SINGLE-USE per CARTON / 10 mL in 1 VIAL, SINGLE-USE (3 VIAL, SINGLE-USE in 1 C ) (NDC: 47335058142)
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 | $1,170.28 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | None | $1,170.28 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | None | $1,170.28 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | None | $1,170.28 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | None | $1,387.10 |
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 |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | None | $1,387.10 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | P | $1,384.35 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | P | $1,384.35 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | P | $1,384.35 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | P | $1,384.35 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Injectable Drugs |
25% | 25% | P | $1,334.10 |
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 |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Injectable Drugs |
25% | 25% | P | $1,334.10 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
25% | 25% | P | $1,334.10 |
Browse Plan Formulary |
Bridges Drug Savings (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$9.00 | $18.00 | None | $1,306.82 |
Browse Plan Formulary |
Bridges Drug Savings (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$9.00 | $18.00 | None | $1,306.82 |
Browse Plan Formulary |
Care1st AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | P | $1,309.27 |
Browse Plan Formulary |
Care1st AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | P | $1,309.27 |
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 |
1 |
Generic Drugs |
0% | 0% | P | $1,309.27 |
Browse Plan Formulary |
Care1st Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Generic Drugs |
0% | 0% | P | $1,309.27 |
Browse Plan Formulary |
CareMore Breathe (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,272.81 |
Browse Plan Formulary |
CareMore Breathe (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,272.81 |
Browse Plan Formulary |
CareMore Cal MediConnect Medicare-Medicaid Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | 0% | None | $1,272.81 |
Browse Plan Formulary |
CareMore Cal MediConnect Medicare-Medicaid Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Tier 1 |
0% | 0% | None | $1,272.81 |
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 | None | $1,272.81 |
Browse Plan Formulary |
CareMore Connect (HMO SNP)
|
$0.00 |
$360 |
to be determined |
5 |
Tier 5 |
25% | n/a | None | $1,272.81 |
Browse Plan Formulary |
CareMore ESRD (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,272.81 |
Browse Plan Formulary |
CareMore ESRD (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,272.81 |
Browse Plan Formulary |
CareMore Heart (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,272.81 |
Browse Plan Formulary |
CareMore Heart (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,272.81 |
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 | None | $1,272.81 |
Browse Plan Formulary |
CareMore Reliance (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,272.81 |
Browse Plan Formulary |
CareMore StartSmart Plus (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,272.81 |
Browse Plan Formulary |
CareMore StartSmart Plus (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,272.81 |
Browse Plan Formulary |
CareMore Touch (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,272.81 |
Browse Plan Formulary |
CareMore Touch (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,272.81 |
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 | None | $1,272.81 |
Browse Plan Formulary |
CareMore Value Plus (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,272.81 |
Browse Plan Formulary |
Central Health Focus Plan (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | P | $1,272.81 |
Browse Plan Formulary |
Central Health Focus Plan (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | P | $1,272.81 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | P | $1,272.81 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | P | $1,272.81 |
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 |
2 |
Generic |
$9.00 | $18.00 | None | $1,308.54 |
Browse Plan Formulary |
Classic Care (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$9.00 | $18.00 | None | $1,308.54 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | P | $1,506.21 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | P | $1,506.21 |
Browse Plan Formulary |
Golden State Medicare Health Plan, Golden (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | 33% | None | $1,316.96 |
Browse Plan Formulary |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Generic Drugs |
0% | 0% | None | $1,424.56 |
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 |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Generic Drugs |
0% | 0% | None | $1,424.56 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$10.00 | $20.00 | None | $1,455.90 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$10.00 | $20.00 | None | $1,455.90 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$10.00 | $20.00 | None | $1,455.90 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$10.00 | $20.00 | None | $1,455.90 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$10.00 | $20.00 | None | $1,455.90 |
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 |
2 |
Generic |
$10.00 | $20.00 | None | $1,455.90 |
Browse Plan Formulary |
Healthy Heart Drug Savings (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$9.00 | $18.00 | None | $1,308.54 |
Browse Plan Formulary |
Healthy Heart Drug Savings (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$9.00 | $18.00 | None | $1,308.54 |
Browse Plan Formulary |
Heart & Diabetes (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$75.00 | $150.00 | None | $1,240.84 |
Browse Plan Formulary |
Heart & Diabetes (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$75.00 | $150.00 | None | $1,240.84 |
Browse Plan Formulary |
Hope Drug Savings (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$9.00 | $18.00 | None | $1,308.54 |
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 |
Hope Drug Savings (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$9.00 | $18.00 | None | $1,308.54 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | P | $1,768.96 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | P | $1,768.96 |
Browse Plan Formulary |
In Control Drug Savings (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$9.00 | $18.00 | None | $1,308.54 |
Browse Plan Formulary |
In Control Drug Savings (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$9.00 | $18.00 | None | $1,308.54 |
Browse Plan Formulary |
Inter Valley Health Plan Service To Seniors (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P | $1,272.81 |
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 | $1,435.33 |
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 | $1,435.33 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$10.00 | $20.00 | None | $1,435.33 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$10.00 | $20.00 | None | $1,435.33 |
Browse Plan Formulary |
L.A Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Generic Drugs |
0% | 0% | P | $1,313.24 |
Browse Plan Formulary |
L.A Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Generic Drugs |
0% | 0% | P | $1,313.24 |
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 Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | P | $1,420.32 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | P | $1,420.32 |
Browse Plan Formulary |
My Choice Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$75.00 | $150.00 | None | $1,240.84 |
Browse Plan Formulary |
My Choice Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$75.00 | $150.00 | None | $1,240.84 |
Browse Plan Formulary |
PHP (HMO SNP)
|
$0.00 |
$360 |
to be determined |
1 |
Generic |
25% | n/a | None | $1,316.68 |
Browse Plan Formulary |
PHP (HMO SNP)
|
$0.00 |
$360 |
to be determined |
1 |
Generic |
25% | n/a | None | $1,316.68 |
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 |
to be determined |
4 |
Non-Preferred Brand |
$75.00 | $150.00 | None | $1,240.84 |
Browse Plan Formulary |
Platinum Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$75.00 | $150.00 | None | $1,240.84 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | P | $1,388.61 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | P | $1,388.61 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | P | $1,388.61 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | P | $1,388.61 |
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 |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | P | $1,388.61 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | P | $1,388.61 |
Browse Plan Formulary |
Easy Choice Freedom Plan (HMO SNP)
|
$8.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | P | $1,506.21 |
Browse Plan Formulary |
Easy Choice Freedom Plan (HMO SNP)
|
$8.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | P | $1,506.21 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$12.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | P | $1,506.21 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$12.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | P | $1,506.21 |
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 | P | $1,424.91 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$18.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | P | $1,424.91 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$20.00 |
$0 |
to be determined |
2 |
Generic |
$10.00 | $20.00 | None | $1,455.90 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$20.00 |
$0 |
to be determined |
2 |
Generic |
$10.00 | $20.00 | None | $1,455.90 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$20.00 |
$0 |
to be determined |
2 |
Generic |
$10.00 | $20.00 | None | $1,455.90 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$20.00 |
$0 |
to be determined |
2 |
Generic |
$10.00 | $20.00 | None | $1,455.90 |
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% | None | $1,272.81 |
Browse Plan Formulary |
CareMore Connect Plus (HMO)
|
$22.00 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $1,272.81 |
Browse Plan Formulary |
Humana Gold Plus H5619-037 (HMO)
|
$23.40 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | P | $1,768.96 |
Browse Plan Formulary |
Humana Gold Plus H5619-037 (HMO)
|
$23.40 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | P | $1,768.96 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$25.20 |
$0 |
to be determined |
2 |
Generic |
$17.00 | $34.00 | None | $1,435.33 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$25.20 |
$0 |
to be determined |
2 |
Generic |
$17.00 | $34.00 | None | $1,435.33 |
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 |
5 |
Specialty Tier |
33% | n/a | None | $1,387.10 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$27.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | None | $1,387.10 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 3 (HMO)
|
$27.40 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $1,170.28 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 3 (HMO)
|
$27.40 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | None | $1,170.28 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$31.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | P | $1,384.35 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$31.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | P | $1,384.35 |
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 |
2* |
Generic |
0% | 0% | None | $1,306.82 |
Browse Plan Formulary |
Bridges - Dual Access (HMO SNP)
|
$31.00 |
$360* |
to be determined |
2* |
Generic |
0% | 0% | None | $1,306.82 |
Browse Plan Formulary |
CalPlus Plan (HMO)
|
$31.00 |
$360 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,240.84 |
Browse Plan Formulary |
CalPlus Plan (HMO)
|
$31.00 |
$360 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,240.84 |
Browse Plan Formulary |
Care1st TotalDual Plan (HMO SNP)
|
$31.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | 25% | P | $1,309.27 |
Browse Plan Formulary |
Care1st TotalDual Plan (HMO SNP)
|
$31.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | 25% | P | $1,309.27 |
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 Choice for Medi-Medi (HMO)
|
$31.00 |
$360* |
to be determined |
2* |
Generic |
0% | 0% | None | $1,308.54 |
Browse Plan Formulary |
Classic Choice for Medi-Medi (HMO)
|
$31.00 |
$360* |
to be determined |
2* |
Generic |
0% | 0% | None | $1,308.54 |
Browse Plan Formulary |
Coordinated Choice Plan (HMO)
|
$31.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | 25% | P | $1,309.27 |
Browse Plan Formulary |
Coordinated Choice Plan (HMO)
|
$31.00 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | 25% | P | $1,309.27 |
Browse Plan Formulary |
Dual Coverage (HMO SNP)
|
$31.00 |
$360* |
to be determined |
2* |
Generic |
$0.00 | $0.00 | None | $1,308.54 |
Browse Plan Formulary |
Dual Coverage (HMO SNP)
|
$31.00 |
$360* |
to be determined |
2* |
Generic |
$0.00 | $0.00 | None | $1,308.54 |
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 |
Harmony - Dual Access (HMO SNP)
|
$31.00 |
$360 |
to be determined |
2 |
Generic |
$13.00 | $26.00 | None | $1,308.54 |
Browse Plan Formulary |
Harmony - Dual Access (HMO SNP)
|
$31.00 |
$360 |
to be determined |
2 |
Generic |
$13.00 | $26.00 | None | $1,308.54 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$31.00 |
$270 |
to be determined |
2 |
Generic |
$20.00 | $40.00 | None | $1,424.56 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$31.00 |
$270 |
to be determined |
2 |
Generic |
$20.00 | $40.00 | None | $1,424.56 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$31.00 |
$280 |
to be determined |
2 |
Generic |
$20.00 | $40.00 | None | $1,424.56 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$31.00 |
$280 |
to be determined |
2 |
Generic |
$20.00 | $40.00 | None | $1,424.56 |
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 |
Health Net Seniority Plus Amber II (HMO SNP)
|
$31.00 |
$280 |
to be determined |
2 |
Generic |
$20.00 | $40.00 | None | $1,424.56 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$31.00 |
$280 |
to be determined |
2 |
Generic |
$20.00 | $40.00 | None | $1,424.56 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$31.00 |
$290 |
to be determined |
2 |
Generic |
$20.00 | $40.00 | None | $1,424.56 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$31.00 |
$290 |
to be determined |
2 |
Generic |
$20.00 | $40.00 | None | $1,424.56 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$31.00 |
$290 |
to be determined |
2 |
Generic |
$20.00 | $40.00 | None | $1,424.56 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$31.00 |
$290 |
to be determined |
2 |
Generic |
$20.00 | $40.00 | None | $1,424.56 |
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 |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$31.00 |
$310 |
to be determined |
2 |
Generic |
$20.00 | $40.00 | None | $1,424.56 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$31.00 |
$310 |
to be determined |
2 |
Generic |
$20.00 | $40.00 | None | $1,424.56 |
Browse Plan Formulary |
Healthy Heart - Dual Access (HMO SNP)
|
$31.00 |
$360* |
to be determined |
2* |
Generic |
0% | 0% | None | $1,308.54 |
Browse Plan Formulary |
Healthy Heart - Dual Access (HMO SNP)
|
$31.00 |
$360* |
to be determined |
2* |
Generic |
0% | 0% | None | $1,308.54 |
Browse Plan Formulary |
In Control - Dual Access (HMO SNP)
|
$31.00 |
$360* |
to be determined |
2* |
Generic |
0% | 0% | None | $1,308.54 |
Browse Plan Formulary |
In Control - Dual Access (HMO SNP)
|
$31.00 |
$360* |
to be determined |
2* |
Generic |
0% | 0% | None | $1,308.54 |
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 Advance Plan (HMO SNP)
|
$31.10 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | P | $1,272.81 |
Browse Plan Formulary |
Central Health Advance Plan (HMO SNP)
|
$31.10 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | P | $1,272.81 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO SNP)
|
$31.10 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | P | $1,272.81 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO SNP)
|
$31.10 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | P | $1,272.81 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$31.10 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | P | $1,272.81 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$31.10 |
$360 |
to be determined |
5 |
Specialty Tier |
25% | n/a | P | $1,272.81 |
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)
|
$31.10 |
$360 |
to be determined |
5 |
Tier 5 |
$0.00 | $0.00 | P | $1,388.61 |
Browse Plan Formulary |
SCAN Connections (HMO SNP)
|
$31.10 |
$360 |
to be determined |
5 |
Tier 5 |
$0.00 | $0.00 | P | $1,388.61 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
|
$31.10 |
$360 |
to be determined |
5 |
Tier 5 |
$0.00 | $0.00 | P | $1,388.61 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
|
$31.10 |
$360 |
to be determined |
5 |
Tier 5 |
$0.00 | $0.00 | P | $1,388.61 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$31.10 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | P | $1,388.61 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$31.10 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | P | $1,388.61 |
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 |
VillageHealth (HMO-POS SNP)
|
$31.10 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | P | $1,388.61 |
Browse Plan Formulary |
VillageHealth (HMO-POS SNP)
|
$31.10 |
$360 |
to be determined |
5 |
Tier 5 |
25% | 25% | P | $1,388.61 |
Browse Plan Formulary |
Humana Gold Plus H5619-022 (HMO)
|
$39.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | P | $1,768.96 |
Browse Plan Formulary |
Humana Gold Plus H5619-022 (HMO)
|
$39.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | P | $1,768.96 |
Browse Plan Formulary |