Hydrocortisone and Acetic Acid 2.41; 3.15g/100mL; g/100mL 1 BOTTLE per CARTON / 10 mL in 1 BOTTLE (1 BOTTLE in 1 CARTON / 10 ) (NDC: 45963041261)
2017 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 |
3 |
Tier 3 |
$47.00 | $131.00 | None | $75.39 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
$47.00 | $131.00 | None | $75.39 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $84.31 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $84.31 |
Browse Plan Formulary |
Alignment Health Plan Heart & Diabetes (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $10.00 | None | $132.58 |
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 |
Alignment Health Plan Heart & Diabetes (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $10.00 | None | $132.58 |
Browse Plan Formulary |
Alignment Health Plan My Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $10.00 | None | $133.42 |
Browse Plan Formulary |
Alignment Health Plan My Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $10.00 | None | $133.42 |
Browse Plan Formulary |
Alignment Health Plan Platinum (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $10.00 | None | $132.58 |
Browse Plan Formulary |
Alignment Health Plan Platinum (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $10.00 | None | $132.58 |
Browse Plan Formulary |
Alignment Health Plan smartHMO (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $20.00 | None | $132.58 |
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 |
Alignment Health Plan smartHMO (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $20.00 | None | $132.58 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$95.00 | n/a | None | $139.37 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$95.00 | n/a | None | $138.92 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | n/a | None | $77.52 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | n/a | None | $77.52 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | n/a | None | $77.52 |
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 AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | n/a | None | $121.67 |
Browse Plan Formulary |
Care1st AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | n/a | None | $121.67 |
Browse Plan Formulary |
Care1st Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | n/a | None | $120.23 |
Browse Plan Formulary |
Care1st Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | n/a | None | $120.23 |
Browse Plan Formulary |
CareMore Breathe (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$9.50 | n/a | None | $80.82 |
Browse Plan Formulary |
CareMore Breathe (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$9.50 | n/a | None | $80.82 |
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 Cal MediConnect Medicare-Medicaid Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | n/a | None | $80.82 |
Browse Plan Formulary |
CareMore Cal MediConnect Medicare-Medicaid Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | n/a | None | $80.82 |
Browse Plan Formulary |
CareMore Connect (HMO SNP)
|
$0.00 |
$400* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$0.00 | n/a | None | $80.82 |
Browse Plan Formulary |
CareMore Connect (HMO SNP)
|
$0.00 |
$400* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$0.00 | n/a | None | $80.82 |
Browse Plan Formulary |
CareMore ESRD (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$9.50 | n/a | None | $80.82 |
Browse Plan Formulary |
CareMore ESRD (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$9.50 | n/a | None | $80.82 |
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 Heart (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$9.50 | n/a | None | $80.82 |
Browse Plan Formulary |
CareMore Heart (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$9.50 | n/a | None | $80.82 |
Browse Plan Formulary |
CareMore Reliance (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$9.50 | n/a | None | $80.82 |
Browse Plan Formulary |
CareMore Reliance (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$9.50 | n/a | None | $80.82 |
Browse Plan Formulary |
CareMore StartSmart Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$14.50 | n/a | None | $80.82 |
Browse Plan Formulary |
CareMore StartSmart Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$14.50 | n/a | None | $80.82 |
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 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$9.50 | n/a | None | $80.82 |
Browse Plan Formulary |
CareMore Touch (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$9.50 | n/a | None | $80.82 |
Browse Plan Formulary |
CareMore Value Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$9.50 | n/a | None | $80.82 |
Browse Plan Formulary |
CareMore Value Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$9.50 | n/a | None | $80.82 |
Browse Plan Formulary |
Central Health Focus Plan (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | n/a | None | $80.82 |
Browse Plan Formulary |
Central Health Focus Plan (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | n/a | None | $80.82 |
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)
|
$0.00 |
$400* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$0.00 | n/a | None | $80.82 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | n/a | None | $80.82 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | n/a | None | $80.82 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$15.00 | $37.50 | None | $133.62 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$15.00 | $37.50 | None | $133.62 |
Browse Plan Formulary |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | n/a | None | $85.60 |
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 |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | n/a | None | $85.60 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None | $99.63 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None | $99.63 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None | $99.63 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None | $99.63 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None | $99.63 |
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 |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None | $99.63 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None | $99.63 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None | $99.63 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $109.77 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $109.77 |
Browse Plan Formulary |
Inter Valley Health Plan Service To Seniors (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | n/a | None | $80.82 |
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 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | n/a | None | $56.31 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | n/a | None | $56.31 |
Browse Plan Formulary |
L.A Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | n/a | None | $135.71 |
Browse Plan Formulary |
L.A Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | n/a | None | $135.71 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$2.00 | n/a | None | $100.01 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$2.00 | n/a | None | $100.01 |
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 Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | n/a | None | $100.06 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | n/a | None | $100.06 |
Browse Plan Formulary |
SCAN Classic II (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | n/a | None | $100.06 |
Browse Plan Formulary |
SCAN Classic II (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | n/a | None | $100.06 |
Browse Plan Formulary |
SCAN Connections (HMO SNP)
|
$0.00 |
$400 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
25% | n/a | None | $100.05 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
|
$0.00 |
$400 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
25% | n/a | None | $100.06 |
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 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | n/a | None | $100.01 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | n/a | None | $100.01 |
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 |
Generic |
$20.00 | n/a | None | $70.66 |
Browse Plan Formulary |
Golden State Medicare Health Plan, Golden (HMO)
|
$4.40 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$15.00 | n/a | None | $143.71 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$5.80 |
$0 |
to be determined |
2 |
Tier 2 |
$12.00 | n/a | None | $70.66 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$5.80 |
$0 |
to be determined |
2 |
Tier 2 |
$12.00 | n/a | None | $70.66 |
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 Choice Plan (PPO)
|
$12.60 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $84.31 |
Browse Plan Formulary |
Humana Gold Plus H5619-037 (HMO)
|
$16.50 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $109.77 |
Browse Plan Formulary |
Humana Gold Plus H5619-037 (HMO)
|
$16.50 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $109.77 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$20.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None | $99.63 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$20.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None | $99.63 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$24.80 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $84.21 |
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 |
AARP MedicareComplete SecureHorizons Plan 3 (HMO)
|
$26.70 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | n/a | None | $74.84 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$27.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $84.21 |
Browse Plan Formulary |
Central Health Advance Plan (HMO SNP)
|
$29.70 |
$400* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$0.00 | n/a | None | $80.82 |
Browse Plan Formulary |
Central Health Advance Plan (HMO SNP)
|
$29.70 |
$400* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$0.00 | n/a | None | $80.82 |
Browse Plan Formulary |
SCAN Connections (HMO SNP)
|
$30.80 |
$400 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
25% | n/a | None | $100.05 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$32.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | n/a | None | $70.66 |
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 Plus Plan (HMO)
|
$33.10 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $50.00 | None | $133.61 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$33.10 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $50.00 | None | $133.61 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
|
$33.80 |
$400 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
25% | n/a | None | $100.06 |
Browse Plan Formulary |
CareMore Connect Plus (HMO)
|
$36.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | None | $80.82 |
Browse Plan Formulary |
CareMore Connect Plus (HMO)
|
$36.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | None | $80.82 |
Browse Plan Formulary |
Care1st TotalDual Plan (HMO SNP)
|
$36.20 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | n/a | None | $120.23 |
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)
|
$36.20 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | n/a | None | $120.23 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO SNP)
|
$36.20 |
$400* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$0.00 | n/a | None | $80.82 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$36.20 |
$400* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$0.00 | n/a | None | $80.82 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$36.20 |
$400* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$0.00 | n/a | None | $80.82 |
Browse Plan Formulary |
Coordinated Choice Plan (HMO)
|
$36.20 |
$400 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
25% | n/a | None | $123.60 |
Browse Plan Formulary |
Coordinated Choice Plan (HMO)
|
$36.20 |
$400 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
25% | n/a | None | $123.60 |
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 |
Health Net Seniority Plus Amber I (HMO SNP)
|
$36.20 |
$175 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | $290.00 | None | $85.60 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$36.20 |
$175 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | $290.00 | None | $85.60 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$36.20 |
$155 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | $290.00 | None | $85.60 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$36.20 |
$155 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | $290.00 | None | $85.60 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$36.20 |
$155 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | $290.00 | None | $85.60 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$36.20 |
$155 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | $290.00 | None | $85.60 |
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 |
Health Net Seniority Plus Amber II (HMO SNP)
|
$36.20 |
$155 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | $290.00 | None | $85.60 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$36.20 |
$155 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | $290.00 | None | $85.60 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$36.20 |
$140 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | $290.00 | None | $85.60 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$36.20 |
$140 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | $290.00 | None | $85.60 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$36.20 |
$140 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | $290.00 | None | $85.60 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$36.20 |
$140 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | $290.00 | None | $85.60 |
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 |
Health Net Seniority Plus Sapphire (HMO)
|
$36.20 |
$140 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | $290.00 | None | $85.60 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$36.20 |
$140 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | $290.00 | None | $85.60 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$36.20 |
$170 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | $290.00 | None | $85.60 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$36.20 |
$170 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | $290.00 | None | $85.60 |
Browse Plan Formulary |
Inter Valley Health Plan Value Preferred Choice (HMO)
|
$36.20 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $80.82 |
Browse Plan Formulary |
Alignment Health Plan CalPlus (HMO)
|
$36.30 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $130.15 |
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 |
Alignment Health Plan CalPlus (HMO)
|
$36.30 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $130.15 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$36.30 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$92.00 | n/a | None | $139.37 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$36.30 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | n/a | None | $99.98 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$36.30 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | n/a | None | $99.98 |
Browse Plan Formulary |
VillageHealth (HMO-POS SNP)
|
$36.30 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | n/a | None | $100.01 |
Browse Plan Formulary |
VillageHealth (HMO-POS SNP)
|
$36.30 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | n/a | None | $100.01 |
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 Choice Plan (PPO)
|
$73.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $84.31 |
Browse Plan Formulary |