CROMOLYN SODIUM 100 MG/5 ML (NDC: 16571060096)
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 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $315.54 |
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 | None | $315.54 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $315.54 |
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 | None | $315.54 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $240.66 |
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 Prime Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $240.66 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $243.87 |
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 | None | $243.87 |
Browse Plan Formulary |
Alignment Health Plan Heart & Diabetes (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$5.00 | n/a | None | $423.88 |
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 | n/a | None | $423.88 |
Browse Plan Formulary |
Alignment Health Plan My Choice (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$5.00 | n/a | None | $423.79 |
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 My Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | n/a | None | $423.79 |
Browse Plan Formulary |
Alignment Health Plan Platinum (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$3.00 | n/a | None | $423.88 |
Browse Plan Formulary |
Alignment Health Plan Platinum (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$3.00 | n/a | None | $423.88 |
Browse Plan Formulary |
Alignment Health Plan smartHMO (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$10.00 | n/a | None | $423.88 |
Browse Plan Formulary |
Alignment Health Plan smartHMO (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | n/a | None | $423.88 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | n/a | None | $409.85 |
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 Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | None | $409.85 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | n/a | None | $418.83 |
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 | None | $418.83 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | n/a | None | $453.00 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$95.00 | n/a | None | $453.00 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$95.00 | n/a | None | $453.00 |
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 |
to be determined |
2 |
Generic |
$5.00 | n/a | None | $394.55 |
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 | $394.55 |
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 | $404.68 |
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 | $404.68 |
Browse Plan Formulary |
Care1st TotalDual Plan (HMO SNP)
|
$0.00 |
$405 |
to be determined |
2 |
Tier 2 |
15% | n/a | None | $404.68 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Specialty Tier |
33% | n/a | None | $397.15 |
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 |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $397.15 |
Browse Plan Formulary |
Easy Choice Freedom Plan (HMO SNP)
|
$0.00 |
$405 |
to be determined |
5 |
Specialty Tier |
25% | n/a | None | $397.15 |
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 | None | $426.45 |
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 | None | $422.61 |
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 | None | $437.88 |
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 | $358.90 |
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 Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | n/a | None | $358.90 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None | $383.50 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None | $372.12 |
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 | $383.50 |
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 | $372.12 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None | $383.50 |
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 | None | $372.12 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Brand |
$90.00 | $260.00 | None | $371.98 |
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 | $371.98 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $380.27 |
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 | $380.27 |
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 | $314.38 |
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 |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$15.00 | n/a | None | $569.93 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$15.00 | n/a | None | $569.93 |
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 | $714.89 |
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 | $714.89 |
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 | None | $410.88 |
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 | None | $410.88 |
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 |
5 |
Specialty Tier |
25% | n/a | None | $410.89 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | n/a | None | $343.13 |
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 | $343.13 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | n/a | None | $345.77 |
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 | $345.77 |
Browse Plan Formulary |
SCAN Classic II (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | n/a | None | $345.77 |
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 |
4 |
Non-Preferred Drug |
25% | n/a | None | $349.61 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
|
$0.00 |
$405 |
to be determined |
4 |
Non-Preferred Drug |
25% | n/a | None | $345.77 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | n/a | None | $346.77 |
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 | $346.77 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$17.00 | n/a | None | $569.93 |
Browse Plan Formulary |
Traditional-LA (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$90.00 | n/a | None | $317.69 |
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 |
2 |
Tier 2 |
$15.00 | n/a | None | $569.93 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$12.70 |
$0 |
to be determined |
2 |
Tier 2 |
$15.00 | n/a | None | $569.93 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$16.30 |
$405 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $380.27 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$16.30 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $380.27 |
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 | None | $383.50 |
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 | None | $372.12 |
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 |
AARP MedicareComplete SecureHorizons Plan 3 (HMO)
|
$17.30 |
$405 |
to be determined |
4 |
Tier 4 |
25% | n/a | None | $309.88 |
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 | None | $309.88 |
Browse Plan Formulary |
Easy Choice Freedom Plan (HMO SNP)
|
$19.60 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $397.15 |
Browse Plan Formulary |
SCAN Classic II (HMO)
|
$24.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | n/a | None | $345.77 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Premier (HMO)
|
$26.70 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $315.54 |
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 | None | $315.54 |
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 |
Easy Choice Plus Plan (HMO)
|
$28.30 |
$405 |
to be determined |
5 |
Specialty Tier |
25% | n/a | None | $397.15 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$28.30 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $397.15 |
Browse Plan Formulary |
SCAN Connections (HMO SNP)
|
$30.00 |
$405 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | n/a | None | $349.61 |
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 |
$17.00 | n/a | None | $569.93 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$32.30 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $240.66 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
|
$35.20 |
$405 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | n/a | None | $345.77 |
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)
|
$35.50 |
$405 |
to be determined |
2 |
Generic |
$10.00 | n/a | None | $423.79 |
Browse Plan Formulary |
Alignment Health Plan CalPlus (HMO)
|
$35.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | n/a | None | $423.79 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$35.50 |
$405 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | n/a | None | $409.85 |
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 | None | $409.85 |
Browse Plan Formulary |
Care1st TotalDual Plan (HMO SNP)
|
$35.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | n/a | None | $404.68 |
Browse Plan Formulary |
Coordinated Choice Plan (HMO)
|
$35.50 |
$405 |
to be determined |
2 |
Generic |
25% | n/a | None | $400.17 |
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 |
Coordinated Choice Plan (HMO)
|
$35.50 |
$405 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
25% | n/a | None | $400.17 |
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 | None | $358.90 |
Browse Plan Formulary |
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 | None | $358.90 |
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 | None | $358.90 |
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 | None | $358.90 |
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 | None | $358.90 |
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 Seniority Plus Amber II (HMO SNP)
|
$35.50 |
$190 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | n/a | None | $358.90 |
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 | None | $358.90 |
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 | None | $358.90 |
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 | None | $358.90 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$35.50 |
$240 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | n/a | None | $358.90 |
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 | None | $358.90 |
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 Seniority Plus Sapphire (HMO)
|
$35.50 |
$240 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | n/a | None | $358.90 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$35.50 |
$240 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | n/a | None | $358.90 |
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 | None | $358.90 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$35.50 |
$85 |
to be determined |
4 |
Non-Preferred Brand |
$100.00 | n/a | None | $358.90 |
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 | None | $358.90 |
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 | None | $313.85 |
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)
|
$35.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $410.89 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$35.50 |
$405 |
to be determined |
4 |
Non-Preferred Drug |
25% | n/a | None | $349.56 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$35.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | n/a | None | $349.56 |
Browse Plan Formulary |
Traditional Plus-LA (HMO)
|
$35.50 |
$405 |
to be determined |
4 |
Non-Preferred Drug |
25% | n/a | None | $317.69 |
Browse Plan Formulary |
VillageHealth (HMO-POS SNP)
|
$35.50 |
$405 |
to be determined |
4 |
Non-Preferred Drug |
25% | n/a | None | $343.13 |
Browse Plan Formulary |
VillageHealth (HMO-POS SNP)
|
$35.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | n/a | None | $343.13 |
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 | None | $240.66 |
Browse Plan Formulary |