APTIOM 400 MG TABLET (30 EA ) (NDC: 63402020430)
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 |
5 |
Tier 5 |
33% | 33% | Q:30 /30Days | $889.67 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
33% | 33% | Q:30 /30Days | $889.67 |
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 | P Q:30 /30Days | $851.18 |
Browse Plan Formulary |
Alignment Health Plan Heart & Diabetes (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $845.00 |
Browse Plan Formulary |
Alignment Health Plan My Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $847.15 |
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 Platinum (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $845.00 |
Browse Plan Formulary |
Alignment Health Plan smartHMO (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $845.00 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
33% | n/a | S | $828.52 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
33% | n/a | S | $825.52 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$88.00 | n/a | P Q:30 /30Days | $830.36 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$65.00 | n/a | P Q:30 /30Days | $830.36 |
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. |
5 |
Specialty Tier |
33% | n/a | S | $818.80 |
Browse Plan Formulary |
Care1st AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $847.13 |
Browse Plan Formulary |
CareMore Breathe (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | n/a | None | $863.12 |
Browse Plan Formulary |
CareMore ESRD (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | n/a | None | $863.12 |
Browse Plan Formulary |
CareMore Heart (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | n/a | None | $863.12 |
Browse Plan Formulary |
CareMore Reliance (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | n/a | None | $863.12 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
CareMore StartSmart Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | n/a | None | $863.12 |
Browse Plan Formulary |
CareMore Touch (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | n/a | None | $863.12 |
Browse Plan Formulary |
CareMore Value Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | n/a | None | $863.12 |
Browse Plan Formulary |
Central Health Focus Plan (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:90 /30Days | $853.66 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:90 /30Days | $853.66 |
Browse Plan Formulary |
Classic Care (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | S | $818.80 |
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 |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $851.12 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | None | $858.70 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | None | $855.88 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | None | $855.81 |
Browse Plan Formulary |
Healthy Heart Drug Savings (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | S | $818.80 |
Browse Plan Formulary |
Heart First (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | None | $830.08 |
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 |
Hope Drug Savings (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | S | $818.80 |
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 | P Q:30 /30Days | $833.63 |
Browse Plan Formulary |
In Control Drug Savings (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | S | $818.80 |
Browse Plan Formulary |
Inter Valley Health Plan OC Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:90 /30Days | $863.12 |
Browse Plan Formulary |
Inter Valley Health Plan Service To Seniors (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | Q:90 /30Days | $863.12 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | n/a | None | $884.62 |
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 |
OneCare Connect (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | P Q:60 /30Days | $873.63 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | None | $834.29 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | None | $830.08 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | None | $833.24 |
Browse Plan Formulary |
Golden State Medicare Health Plan, Golden (HMO)
|
$4.40 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $832.69 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$5.80 |
$0 |
to be determined |
4 |
Tier 4 |
$95.00 | n/a | None | $912.43 |
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 H5619-037 (HMO)
|
$16.50 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days | $833.62 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$20.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | None | $858.70 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$20.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | None | $855.88 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 3 (HMO)
|
$26.70 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | n/a | Q:30 /30Days | $883.95 |
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 | P Q:30 /30Days | $849.98 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$27.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $851.12 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$32.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | n/a | None | $912.43 |
Browse Plan Formulary |
OneCare (HMO SNP)
|
$33.50 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Tier 2 |
$0.00 | n/a | P Q:60 /30Days | $873.63 |
Browse Plan Formulary |
CareMore Connect Plus (HMO)
|
$36.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | None | $863.12 |
Browse Plan Formulary |
Care1st TotalDual Plan (HMO SNP)
|
$36.20 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | n/a | P Q:30 /30Days | $847.89 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$36.20 |
$400 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | Q:90 /30Days | $853.66 |
Browse Plan Formulary |
Coordinated Choice Plan (HMO)
|
$36.20 |
$400 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $846.09 |
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 |
5 |
Specialty Tier |
29% | 29% | None | $849.88 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$36.20 |
$155 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | 30% | None | $849.94 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$36.20 |
$155 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | 30% | None | $851.13 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$36.20 |
$155 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | 30% | None | $848.65 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$36.20 |
$140 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | 30% | None | $849.87 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$36.20 |
$140 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | 30% | None | $849.94 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Health Net Seniority Plus Sapphire (HMO)
|
$36.20 |
$140 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | 30% | None | $853.24 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$36.20 |
$170 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | 29% | None | $848.65 |
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 | Q:90 /30Days | $863.12 |
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 | $849.69 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$36.30 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | n/a | S | $828.52 |
Browse Plan Formulary |
Bridges - Dual Access (HMO SNP)
|
$36.30 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | S | $818.80 |
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 |
Classic Choice for Medi-Medi (HMO)
|
$36.30 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | S | $818.80 |
Browse Plan Formulary |
Dual Coverage (HMO SNP)
|
$36.30 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | S | $818.80 |
Browse Plan Formulary |
Harmony - Dual Access (HMO SNP)
|
$36.30 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | S | $818.80 |
Browse Plan Formulary |
Healthy Heart - Dual Access (HMO SNP)
|
$36.30 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | S | $818.80 |
Browse Plan Formulary |
In Control - Dual Access (HMO SNP)
|
$36.30 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | S | $818.80 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$36.30 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | n/a | None | $830.08 |
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 |
VillageHealth (HMO-POS SNP)
|
$36.30 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | n/a | None | $834.29 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$107.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:30 /30Days | $851.18 |
Browse Plan Formulary |
Anthem MediBlue Access (PPO)
|
$150.00 |
$230 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | S | $825.52 |
Browse Plan Formulary |