ARANESP 25ug/mL 4 VIAL, SINGLE-DOSE in 1 PACKAGE / 1 mL in 1 VIAL, SINGLE-DOSE (4 VIAL, SINGLE-DOSE ) (NDC: 55513000204)
2018 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
See your cost using a drug discount card: Compare prices at pharmacies near you |
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 |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $775.01 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $775.01 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $775.01 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $775.01 |
Browse Plan Formulary |
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 Q:4 /28Days | $817.42 |
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 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /28Days | $817.42 |
Browse Plan Formulary |
Alignment Health Plan Heart & Diabetes (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$75.00 | n/a | P | $794.17 |
Browse Plan Formulary |
Alignment Health Plan Heart & Diabetes (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$75.00 | n/a | P | $794.17 |
Browse Plan Formulary |
Alignment Health Plan My Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$75.00 | n/a | P | $793.23 |
Browse Plan Formulary |
Alignment Health Plan My Choice (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$75.00 | n/a | P | $793.23 |
Browse Plan Formulary |
Alignment Health Plan Platinum (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$75.00 | n/a | P | $794.17 |
Browse Plan Formulary |
|
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Alignment Health Plan Platinum (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$75.00 | n/a | P | $794.17 |
Browse Plan Formulary |
Alignment Health Plan smartHMO (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$75.00 | n/a | P | $794.17 |
Browse Plan Formulary |
Alignment Health Plan smartHMO (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$75.00 | n/a | P | $794.17 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | P | $788.21 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | n/a | P | $788.21 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | P | $794.30 |
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 MediBlue Select (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | n/a | P | $794.30 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Injectable Drugs |
30% | n/a | P Q:4 /28Days | $763.34 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Injectable Drugs |
30% | n/a | P Q:4 /28Days | $763.34 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Injectable Drugs |
31% | n/a | P Q:4 /28Days | $763.34 |
Browse Plan Formulary |
Care1st AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$40.00 | n/a | P | $772.25 |
Browse Plan Formulary |
Care1st AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | n/a | P | $772.25 |
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 |
Care1st Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | P | $768.57 |
Browse Plan Formulary |
Care1st Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | n/a | P | $768.57 |
Browse Plan Formulary |
Care1st TotalDual Plan (HMO SNP)
|
$0.00 |
$405 |
to be determined |
3 |
Tier 3 |
15% | n/a | P | $768.57 |
Browse Plan Formulary |
Central Health Focus Plan (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | n/a | P Q:4 /28Days | $795.37 |
Browse Plan Formulary |
Central Health Focus Plan (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$75.00 | n/a | P Q:4 /28Days | $795.37 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO SNP)
|
$0.00 |
$405 |
to be determined |
4 |
Non-Preferred Drug |
25% | n/a | P Q:4 /28Days | $795.20 |
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 Medicare Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$75.00 | n/a | P Q:4 /28Days | $796.24 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | n/a | P Q:4 /28Days | $796.24 |
Browse Plan Formulary |
Golden State Medicare Gold (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | P | $810.80 |
Browse Plan Formulary |
Golden State Medicare Gold (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | P | $810.80 |
Browse Plan Formulary |
Golden State Medicare Gold (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | P | $771.91 |
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 | P | $764.71 |
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 | P | $764.71 |
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 | P | $791.16 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P | $789.45 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P | $791.16 |
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 | P | $789.45 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P | $789.45 |
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 |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P | $791.16 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P | $791.16 |
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 | P | $791.16 |
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 | P Q:4 /28Days | $798.07 |
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 | P | $818.49 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $818.49 |
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 |
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 S | $795.38 |
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 S | $795.38 |
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 | P | $818.49 |
Browse Plan Formulary |
Traditional-LA (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$90.00 | n/a | P Q:4 /28Days | $795.20 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$12.70 |
$0 |
to be determined |
4 |
Tier 4 |
$100.00 | n/a | P | $818.49 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$12.70 |
$0 |
to be determined |
4 |
Tier 4 |
$100.00 | n/a | P | $818.49 |
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)
|
$17.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P | $791.16 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$17.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | P | $789.45 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 3 (HMO)
|
$17.30 |
$405 |
to be determined |
4 |
Tier 4 |
25% | n/a | P | $789.47 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 3 (HMO)
|
$17.30 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | n/a | P | $789.47 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Premier (HMO)
|
$26.70 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $775.01 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Premier (HMO)
|
$26.70 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $775.01 |
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 |
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 | P | $818.49 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$32.30 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /28Days | $817.24 |
Browse Plan Formulary |
Alignment Health Plan CalPlus (HMO)
|
$35.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$93.00 | n/a | P | $793.83 |
Browse Plan Formulary |
Alignment Health Plan CalPlus (HMO)
|
$35.50 |
$405 |
to be determined |
4 |
Non-Preferred Brand |
$93.00 | n/a | P | $793.83 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$35.50 |
$405 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | n/a | P | $788.21 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$35.50 |
$405 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | P | $788.21 |
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 |
Care1st TotalDual Plan (HMO SNP)
|
$35.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | n/a | P | $768.57 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO SNP)
|
$35.50 |
$405 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | n/a | P Q:4 /28Days | $795.20 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$35.50 |
$405 |
to be determined |
4 |
Non-Preferred Drug |
25% | n/a | P Q:4 /28Days | $796.24 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$35.50 |
$405 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | n/a | P Q:4 /28Days | $796.24 |
Browse Plan Formulary |
Coordinated Choice Plan (HMO)
|
$35.50 |
$405 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
25% | n/a | P | $773.43 |
Browse Plan Formulary |
Coordinated Choice Plan (HMO)
|
$35.50 |
$405 |
to be determined |
3 |
Preferred Brand |
25% | n/a | P | $773.43 |
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 |
Health Net Seniority Plus Amber I (HMO SNP)
|
$35.50 |
$140 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $764.96 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$35.50 |
$140 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $764.96 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$35.50 |
$190 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $764.91 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$35.50 |
$190 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $829.48 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$35.50 |
$190 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $764.91 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$35.50 |
$190 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $765.21 |
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 |
Health Net Seniority Plus Amber II (HMO SNP)
|
$35.50 |
$190 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $829.48 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$35.50 |
$190 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $765.21 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$35.50 |
$240 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $765.21 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$35.50 |
$240 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $765.21 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$35.50 |
$240 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $829.48 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$35.50 |
$240 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $829.48 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Health Net Seniority Plus Sapphire (HMO)
|
$35.50 |
$240 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $764.91 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$35.50 |
$240 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $764.91 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$35.50 |
$85 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $764.91 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$35.50 |
$85 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | n/a | P | $764.91 |
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 | P Q:4 /28Days | $797.60 |
Browse Plan Formulary |
Traditional Plus-LA (HMO)
|
$35.50 |
$405 |
to be determined |
4 |
Non-Preferred Drug |
25% | n/a | P Q:4 /28Days | $795.20 |
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)
|
$79.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /28Days | $817.24 |
Browse Plan Formulary |