ANDROGEL 1.62% (1.25G) GEL PCKT (1.5 GM ) (NDC: 00051846231)
2018 Medicare Prescription Drug Plan (MAPD) Information
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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 |
Preferred Brand |
$47.00 | $131.00 | None | $667.25 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $667.25 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $667.25 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $667.25 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $636.38 |
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 |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $636.38 |
Browse Plan Formulary |
Alignment Health Plan Heart & Diabetes (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | n/a | P Q:38 /30Days | $626.73 |
Browse Plan Formulary |
Alignment Health Plan Heart & Diabetes (HMO SNP)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$30.00 | n/a | P Q:38 /30Days | $626.73 |
Browse Plan Formulary |
Alignment Health Plan My Choice (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$30.00 | n/a | P Q:38 /30Days | $626.20 |
Browse Plan Formulary |
Alignment Health Plan My Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | n/a | P Q:38 /30Days | $626.20 |
Browse Plan Formulary |
Alignment Health Plan Platinum (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | n/a | P Q:38 /30Days | $626.73 |
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 |
to be determined |
3 |
Preferred Brand |
$30.00 | n/a | P Q:38 /30Days | $626.73 |
Browse Plan Formulary |
Alignment Health Plan smartHMO (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$30.00 | n/a | P Q:38 /30Days | $626.73 |
Browse Plan Formulary |
Alignment Health Plan smartHMO (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | n/a | P Q:38 /30Days | $626.73 |
Browse Plan Formulary |
Anthem Breathe (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$85.00 | n/a | Q:113 /30Days | $616.65 |
Browse Plan Formulary |
Anthem Breathe (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | n/a | Q:113 /30Days | $616.65 |
Browse Plan Formulary |
Anthem Connect (HMO SNP)
|
$0.00 |
$405 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | n/a | Q:113 /30Days | $616.38 |
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 |
Anthem Connect (HMO SNP)
|
$0.00 |
$405 |
to be determined |
4 |
Non-Preferred Drug |
25% | n/a | Q:113 /30Days | $616.38 |
Browse Plan Formulary |
Anthem Diabetes (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$85.00 | n/a | Q:113 /30Days | $616.65 |
Browse Plan Formulary |
Anthem Diabetes (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | n/a | Q:113 /30Days | $616.65 |
Browse Plan Formulary |
Anthem ESRD (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | n/a | Q:113 /30Days | $616.65 |
Browse Plan Formulary |
Anthem ESRD (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$85.00 | n/a | Q:113 /30Days | $616.65 |
Browse Plan Formulary |
Anthem Heart (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | n/a | Q:113 /30Days | $616.65 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Anthem Heart (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$85.00 | n/a | Q:113 /30Days | $616.65 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$42.00 | n/a | P Q:113 /30Days | $616.68 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | n/a | P Q:113 /30Days | $616.68 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$42.00 | n/a | P Q:113 /30Days | $616.38 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | n/a | P Q:113 /30Days | $616.38 |
Browse Plan Formulary |
Anthem StartSmart Plus (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | n/a | Q:113 /30Days | $616.65 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Anthem StartSmart Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | n/a | Q:113 /30Days | $616.65 |
Browse Plan Formulary |
Anthem Touch (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | n/a | Q:113 /30Days | $616.65 |
Browse Plan Formulary |
Anthem Touch (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$85.00 | n/a | Q:113 /30Days | $616.65 |
Browse Plan Formulary |
Anthem Value Plus (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$85.00 | n/a | Q:113 /30Days | $616.65 |
Browse Plan Formulary |
Anthem Value Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | n/a | Q:113 /30Days | $616.65 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$95.00 | n/a | P Q:38 /30Days | $610.51 |
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 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | n/a | P Q:38 /30Days | $610.51 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$95.00 | n/a | P Q:38 /30Days | $610.51 |
Browse Plan Formulary |
Brand New Day Bridges Drug Savings (HMO SNP)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$45.00 | n/a | P Q:150 /30Days | $611.23 |
Browse Plan Formulary |
Brand New Day Bridges Drug Savings (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | n/a | P Q:150 /30Days | $611.23 |
Browse Plan Formulary |
Brand New Day Classic Care Drug Savings (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | n/a | P Q:150 /30Days | $611.23 |
Browse Plan Formulary |
Brand New Day Classic Care Drug Savings (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$45.00 | n/a | P Q:150 /30Days | $611.23 |
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 |
Brand New Day Embrace Care Drug Savings (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | n/a | P Q:150 /30Days | $611.23 |
Browse Plan Formulary |
Brand New Day Embrace Care Drug Savings (HMO SNP)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$45.00 | n/a | P Q:150 /30Days | $611.23 |
Browse Plan Formulary |
Brand New Day Harmony Drug Savings (HMO SNP)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$45.00 | n/a | P Q:150 /30Days | $611.23 |
Browse Plan Formulary |
Brand New Day Harmony Drug Savings (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | n/a | P Q:150 /30Days | $611.23 |
Browse Plan Formulary |
Brand New Day In Control Drug Savings (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | n/a | P Q:150 /30Days | $611.23 |
Browse Plan Formulary |
Brand New Day In Control Drug Savings (HMO SNP)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$45.00 | n/a | P Q:150 /30Days | $611.23 |
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 |
Central Health Focus Plan (HMO SNP)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$35.00 | n/a | None | $631.43 |
Browse Plan Formulary |
Central Health Focus Plan (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | n/a | None | $631.43 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO SNP)
|
$0.00 |
$405 |
to be determined |
3 |
Preferred Brand |
25% | n/a | None | $631.82 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | n/a | None | $631.94 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$35.00 | n/a | None | $631.94 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $117.50 | P Q:150 /30Days | $631.93 |
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 |
to be determined |
3 |
Preferred Brand |
$47.00 | $117.50 | P Q:150 /30Days | $631.93 |
Browse Plan Formulary |
Easy Choice Freedom Plan (HMO SNP)
|
$0.00 |
$405 |
to be determined |
3 |
Preferred Brand |
$47.00 | $117.50 | P Q:150 /30Days | $631.93 |
Browse Plan Formulary |
Golden State Medicare Gold (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | n/a | P | $619.88 |
Browse Plan Formulary |
Golden State Medicare Gold (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | n/a | P | $620.63 |
Browse Plan Formulary |
Golden State Medicare Gold (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | n/a | P | $620.31 |
Browse Plan Formulary |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | None | $615.80 |
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 |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | None | $615.80 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$37.00 | $101.00 | None | $632.98 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $101.00 | None | $633.68 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $101.00 | None | $632.98 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$37.00 | $101.00 | None | $633.68 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$37.00 | $101.00 | None | $632.98 |
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 |
to be determined |
3 |
Preferred Brand |
$37.00 | $101.00 | None | $633.68 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $101.00 | None | $633.08 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$37.00 | $101.00 | None | $633.08 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:38 /30Days | $620.86 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:38 /30Days | $620.86 |
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 | Q:300 /30Days | $635.72 |
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 |
$100.00 | n/a | None | $685.07 |
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 |
$100.00 | n/a | None | $685.07 |
Browse Plan Formulary |
L.A Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | P Q:38 /30Days | $664.76 |
Browse Plan Formulary |
L.A Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | P Q:38 /30Days | $664.76 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | P Q:150 /30Days | $615.75 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | P Q:150 /30Days | $615.75 |
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 |
Molina Medicare Options Plus (HMO SNP)
|
$0.00 |
$405 |
to be determined |
3 |
Preferred Brand |
$47.00 | n/a | P Q:150 /30Days | $615.74 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$30.00 | n/a | P | $615.51 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | n/a | P | $615.51 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | n/a | P | $615.67 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$42.00 | n/a | P | $615.67 |
Browse Plan Formulary |
SCAN Classic II (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$42.00 | n/a | P | $615.67 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SCAN Connections (HMO SNP)
|
$0.00 |
$405 |
to be determined |
3 |
Preferred Brand |
25% | n/a | P | $616.29 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
|
$0.00 |
$405 |
to be determined |
3 |
Preferred Brand |
25% | n/a | P | $615.67 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$42.00 | n/a | P | $616.00 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | n/a | P | $616.00 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | n/a | None | $671.83 |
Browse Plan Formulary |
Traditional-LA (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$45.00 | n/a | Q:300 /30Days | $636.19 |
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)
|
$12.70 |
$0 |
to be determined |
4 |
Tier 4 |
$100.00 | n/a | None | $671.83 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$12.70 |
$0 |
to be determined |
4 |
Tier 4 |
$100.00 | n/a | None | $671.83 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$16.30 |
$405 |
to be determined |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:38 /30Days | $620.88 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$16.30 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:38 /30Days | $620.88 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$17.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $101.00 | None | $633.68 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$17.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $101.00 | None | $632.98 |
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)
|
$17.30 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | n/a | None | $668.77 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 3 (HMO)
|
$17.30 |
$405 |
to be determined |
3 |
Tier 3 |
25% | n/a | None | $668.77 |
Browse Plan Formulary |
Easy Choice Freedom Plan (HMO SNP)
|
$19.60 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $117.50 | P Q:150 /30Days | $631.93 |
Browse Plan Formulary |
SCAN Classic II (HMO)
|
$24.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | n/a | P | $615.67 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Premier (HMO)
|
$26.70 |
$0 |
to be determined |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $667.25 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Premier (HMO)
|
$26.70 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $667.25 |
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)
|
$28.30 |
$405 |
to be determined |
3 |
Preferred Brand |
$47.00 | $117.50 | P Q:150 /30Days | $631.93 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$28.30 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $117.50 | P Q:150 /30Days | $631.93 |
Browse Plan Formulary |
SCAN Connections (HMO SNP)
|
$30.00 |
$405 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
25% | n/a | P | $616.29 |
Browse Plan Formulary |
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 | $671.83 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$32.30 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $636.36 |
Browse Plan Formulary |
Anthem Connect Plus (HMO)
|
$33.00 |
$405 |
to be determined |
4 |
Tier 4 |
25% | n/a | Q:113 /30Days | $616.65 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Anthem Connect Plus (HMO)
|
$33.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | Q:113 /30Days | $616.65 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
|
$35.20 |
$405 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
25% | n/a | P | $615.67 |
Browse Plan Formulary |
Alignment Health Plan CalPlus (HMO)
|
$35.50 |
$405 |
to be determined |
3 |
Preferred Brand |
$40.00 | n/a | P Q:38 /30Days | $625.90 |
Browse Plan Formulary |
Alignment Health Plan CalPlus (HMO)
|
$35.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | n/a | P Q:38 /30Days | $625.90 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$35.50 |
$405 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | n/a | P Q:113 /30Days | $616.68 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$35.50 |
$405 |
to be determined |
3 |
Preferred Brand |
$47.00 | n/a | P Q:113 /30Days | $616.68 |
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 |
Brand New Day Bridges Choice for Medi-Medi (HMO SNP)
|
$35.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | n/a | P Q:150 /30Days | $611.23 |
Browse Plan Formulary |
Brand New Day Bridges Choice for Medi-Medi (HMO SNP)
|
$35.50 |
$405 |
to be determined |
3 |
Preferred Brand |
25% | n/a | P Q:150 /30Days | $611.23 |
Browse Plan Formulary |
Brand New Day Classic Choice for Medi-Medi (HMO)
|
$35.50 |
$405 |
to be determined |
3 |
Preferred Brand |
25% | n/a | P Q:150 /30Days | $611.23 |
Browse Plan Formulary |
Brand New Day Classic Choice for Medi-Medi (HMO)
|
$35.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | n/a | P Q:150 /30Days | $611.23 |
Browse Plan Formulary |
Brand New Day Dual Coverage (HMO SNP)
|
$35.50 |
$405 |
to be determined |
3 |
Preferred Brand |
25% | n/a | P Q:150 /30Days | $611.23 |
Browse Plan Formulary |
Brand New Day Dual Coverage (HMO SNP)
|
$35.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | n/a | P Q:150 /30Days | $611.23 |
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 |
Brand New Day Embrace Choice for Medi-Medi (HMO SNP)
|
$35.50 |
$405 |
to be determined |
3 |
Preferred Brand |
25% | n/a | P Q:150 /30Days | $611.23 |
Browse Plan Formulary |
Brand New Day Embrace Choice for Medi-Medi (HMO SNP)
|
$35.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | n/a | P Q:150 /30Days | $611.23 |
Browse Plan Formulary |
Brand New Day Harmony Choice for Medi-Medi (HMO SNP)
|
$35.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | n/a | P Q:150 /30Days | $611.23 |
Browse Plan Formulary |
Brand New Day Harmony Choice for Medi-Medi (HMO SNP)
|
$35.50 |
$405 |
to be determined |
3 |
Preferred Brand |
25% | n/a | P Q:150 /30Days | $611.23 |
Browse Plan Formulary |
Brand New Day In Control Choice for Medi-Medi (HMO SNP)
|
$35.50 |
$405 |
to be determined |
3 |
Preferred Brand |
25% | n/a | P Q:150 /30Days | $611.23 |
Browse Plan Formulary |
Brand New Day In Control Choice for Medi-Medi (HMO SNP)
|
$35.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | n/a | P Q:150 /30Days | $611.23 |
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 |
Central Health Medi-Medi Plan (HMO SNP)
|
$35.50 |
$405 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
25% | n/a | None | $631.82 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$35.50 |
$405 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
25% | n/a | None | $631.94 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$35.50 |
$405 |
to be determined |
3 |
Preferred Brand |
25% | n/a | None | $631.94 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$35.50 |
$140 |
to be determined |
3 |
Preferred Brand |
$47.00 | n/a | None | $616.04 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$35.50 |
$140 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | n/a | None | $616.04 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$35.50 |
$190 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | n/a | None | $615.72 |
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)
|
$35.50 |
$190 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | n/a | None | $615.72 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$35.50 |
$190 |
to be determined |
3 |
Preferred Brand |
$47.00 | n/a | None | $615.72 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$35.50 |
$190 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | n/a | None | $616.11 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$35.50 |
$190 |
to be determined |
3 |
Preferred Brand |
$47.00 | n/a | None | $615.72 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$35.50 |
$190 |
to be determined |
3 |
Preferred Brand |
$47.00 | n/a | None | $616.11 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$35.50 |
$240 |
to be determined |
3 |
Preferred Brand |
$47.00 | n/a | None | $615.72 |
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)
|
$35.50 |
$240 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | n/a | None | $615.81 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$35.50 |
$240 |
to be determined |
3 |
Preferred Brand |
$47.00 | n/a | None | $615.81 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$35.50 |
$240 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | n/a | None | $615.72 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$35.50 |
$240 |
to be determined |
3 |
Preferred Brand |
$47.00 | n/a | None | $615.72 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$35.50 |
$240 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | n/a | None | $615.72 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$35.50 |
$85 |
to be determined |
3 |
Preferred Brand |
$47.00 | n/a | None | $616.11 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$35.50 |
$85 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | n/a | None | $616.11 |
Browse Plan Formulary |
Inter Valley Health Plan Value Preferred Choice (HMO)
|
$35.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | Q:300 /30Days | $635.81 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$35.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | n/a | P Q:150 /30Days | $615.74 |
Browse Plan Formulary |
PHP (HMO SNP)
|
$35.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
25% | n/a | P Q:150 /30Days | $605.48 |
Browse Plan Formulary |
PHP (HMO SNP)
|
$35.50 |
$405 |
to be determined |
2 |
Preferred Brand |
25% | n/a | P Q:150 /30Days | $605.48 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$35.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | n/a | P | $616.51 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SCAN Plus (HMO)
|
$35.50 |
$405 |
to be determined |
3 |
Preferred Brand |
25% | n/a | P | $616.51 |
Browse Plan Formulary |
Traditional Plus-LA (HMO)
|
$35.50 |
$405 |
to be determined |
3 |
Preferred Brand |
25% | n/a | Q:300 /30Days | $636.19 |
Browse Plan Formulary |
VillageHealth (HMO-POS SNP)
|
$35.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | n/a | P | $615.51 |
Browse Plan Formulary |
VillageHealth (HMO-POS SNP)
|
$35.50 |
$405 |
to be determined |
3 |
Preferred Brand |
25% | n/a | P | $615.51 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$79.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P | $636.36 |
Browse Plan Formulary |