MINOCYCLINE HYDROCHLORIDE TABLETS 50MG (NDC: 49884051101)
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 | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $140.76 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $140.76 |
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 | $140.76 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $140.76 |
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 | S | $157.24 |
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 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | S | $157.24 |
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 | S | $158.66 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | S | $158.66 |
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 | $116.71 |
Browse Plan Formulary |
Alignment Health Plan Heart & Diabetes (HMO SNP)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$5.00 | n/a | None | $116.71 |
Browse Plan Formulary |
Alignment Health Plan My Choice (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | n/a | None | $120.82 |
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 |
Alignment Health Plan My Choice (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$5.00 | n/a | None | $120.82 |
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 | $116.71 |
Browse Plan Formulary |
Alignment Health Plan Platinum (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$3.00 | n/a | None | $116.71 |
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 | $116.71 |
Browse Plan Formulary |
Alignment Health Plan smartHMO (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$10.00 | n/a | None | $116.71 |
Browse Plan Formulary |
Anthem Breathe (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$7.50 | n/a | None | $150.18 |
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 Breathe (HMO SNP)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$7.50 | n/a | None | $150.18 |
Browse Plan Formulary |
Anthem Connect (HMO SNP)
|
$0.00 |
$405* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$0.00 | n/a | None | $154.42 |
Browse Plan Formulary |
Anthem Connect (HMO SNP)
|
$0.00 |
$405* | to be determined | 2* |
Generic |
$0.00 | n/a | None | $154.42 |
Browse Plan Formulary |
Anthem Diabetes (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$7.50 | n/a | None | $150.18 |
Browse Plan Formulary |
Anthem Diabetes (HMO SNP)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$7.50 | n/a | None | $150.18 |
Browse Plan Formulary |
Anthem ESRD (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$7.50 | n/a | None | $150.18 |
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 ESRD (HMO SNP)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$7.50 | n/a | None | $150.18 |
Browse Plan Formulary |
Anthem Heart (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$7.50 | n/a | None | $150.18 |
Browse Plan Formulary |
Anthem Heart (HMO SNP)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$7.50 | n/a | None | $150.18 |
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 | None | $150.18 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$95.00 | n/a | None | $150.18 |
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 | $154.42 |
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 |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$95.00 | n/a | None | $154.42 |
Browse Plan Formulary |
Anthem StartSmart Plus (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$14.50 | n/a | None | $149.85 |
Browse Plan Formulary |
Anthem StartSmart Plus (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$14.50 | n/a | None | $149.85 |
Browse Plan Formulary |
Anthem Touch (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$9.50 | n/a | None | $150.18 |
Browse Plan Formulary |
Anthem Touch (HMO SNP)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$9.50 | n/a | None | $150.18 |
Browse Plan Formulary |
Anthem Value Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$9.50 | n/a | None | $150.18 |
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 Value Plus (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$9.50 | n/a | None | $150.18 |
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 | $73.87 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Brand |
$95.00 | n/a | None | $73.87 |
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 | $73.87 |
Browse Plan Formulary |
Brand New Day Bridges Drug Savings (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$75.00 | n/a | None | $147.08 |
Browse Plan Formulary |
Brand New Day Bridges Drug Savings (HMO SNP)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$75.00 | n/a | None | $147.08 |
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 |
Brand New Day Classic Care Drug Savings (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$75.00 | n/a | None | $147.08 |
Browse Plan Formulary |
Brand New Day Classic Care Drug Savings (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$75.00 | n/a | None | $147.08 |
Browse Plan Formulary |
Brand New Day Embrace Care Drug Savings (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$75.00 | n/a | None | $147.08 |
Browse Plan Formulary |
Brand New Day Embrace Care Drug Savings (HMO SNP)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$75.00 | n/a | None | $147.08 |
Browse Plan Formulary |
Brand New Day Harmony Drug Savings (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$9.00 | n/a | None | $147.08 |
Browse Plan Formulary |
Brand New Day Harmony Drug Savings (HMO SNP)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$9.00 | n/a | None | $147.08 |
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 |
Brand New Day In Control Drug Savings (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$75.00 | n/a | None | $147.08 |
Browse Plan Formulary |
Brand New Day In Control Drug Savings (HMO SNP)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$75.00 | n/a | None | $147.08 |
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 | $138.85 |
Browse Plan Formulary |
Care1st AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$5.00 | n/a | None | $138.85 |
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 | $135.15 |
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 | $135.15 |
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 |
Care1st TotalDual Plan (HMO SNP)
|
$0.00 |
$405 | to be determined | 2 |
Tier 2 |
15% | n/a | None | $135.15 |
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 | None | $48.72 |
Browse Plan Formulary |
Central Health Focus Plan (HMO SNP)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$75.00 | n/a | None | $48.72 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO SNP)
|
$0.00 |
$405 | to be determined | 4 |
Non-Preferred Drug |
25% | n/a | None | $43.65 |
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 | None | $53.75 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$75.00 | n/a | None | $53.75 |
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 |
Golden State Medicare Gold (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | n/a | None | $145.76 |
Browse Plan Formulary |
Golden State Medicare Gold (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | n/a | None | $144.76 |
Browse Plan Formulary |
Golden State Medicare Gold (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | n/a | None | $144.76 |
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 | $79.48 |
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 | $79.48 |
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 | $127.04 |
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 Gold Select (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$90.00 | $260.00 | None | $132.89 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Brand |
$90.00 | $260.00 | None | $127.04 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Brand |
$90.00 | $260.00 | None | $132.89 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Brand |
$90.00 | $260.00 | None | $127.04 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Brand |
$90.00 | $260.00 | None | $132.89 |
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 | $127.04 |
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 Jade (HMO SNP)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Brand |
$90.00 | $260.00 | None | $127.04 |
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 | None | $85.07 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 | to be determined | 3 |
Preferred Brand |
$35.00 | $70.00 | None | $85.07 |
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 | $53.75 |
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 | $113.71 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$15.00 | n/a | None | $113.71 |
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 |
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 | $167.56 |
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 | $167.56 |
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 | $113.81 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$2.00 | n/a | None | $113.81 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | n/a | None | $113.75 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$5.00 | n/a | None | $113.75 |
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 |
SCAN Classic II (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$5.00 | n/a | None | $113.75 |
Browse Plan Formulary |
SCAN Connections (HMO SNP)
|
$0.00 |
$405 | to be determined | 2 |
Generic |
25% | n/a | None | $115.50 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
|
$0.00 |
$405 | to be determined | 2 |
Generic |
25% | n/a | None | $113.75 |
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 | $115.06 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$5.00 | n/a | None | $115.06 |
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 | $113.83 |
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 |
Traditional-LA (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$90.00 | n/a | None | $40.78 |
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 | $113.83 |
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 | $113.83 |
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 | None | $85.07 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$16.30 |
$405 | to be determined | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $85.07 |
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 | $127.04 |
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 | None | $132.89 |
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 | $135.55 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 3 (HMO)
|
$17.30 |
$405 | to be determined | 4 |
Tier 4 |
25% | n/a | None | $135.55 |
Browse Plan Formulary |
SCAN Classic II (HMO)
|
$24.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | n/a | None | $113.75 |
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 | $140.76 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Premier (HMO)
|
$26.70 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $140.76 |
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)
|
$30.00 |
$405 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
25% | n/a | None | $115.50 |
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 | $113.83 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$32.30 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | S | $157.24 |
Browse Plan Formulary |
Anthem Connect Plus (HMO)
|
$33.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | None | $149.85 |
Browse Plan Formulary |
Anthem Connect Plus (HMO)
|
$33.00 |
$405 | to be determined | 2 |
Tier 2 |
25% | n/a | None | $149.85 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
|
$35.20 |
$405 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
25% | n/a | None | $113.75 |
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 |
Alignment Health Plan CalPlus (HMO)
|
$35.50 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | None | $124.48 |
Browse Plan Formulary |
Alignment Health Plan CalPlus (HMO)
|
$35.50 |
$405 | to be determined | 2 |
Generic |
$10.00 | n/a | None | $124.48 |
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 | $150.18 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$35.50 |
$405 | to be determined | 4 |
Non-Preferred Drug |
$95.00 | n/a | None | $150.18 |
Browse Plan Formulary |
Brand New Day Bridges Choice for Medi-Medi (HMO SNP)
|
$35.50 |
$405 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
25% | n/a | None | $147.08 |
Browse Plan Formulary |
Brand New Day Bridges Choice for Medi-Medi (HMO SNP)
|
$35.50 |
$405 | to be determined | 4 |
Non-Preferred Drug |
25% | n/a | None | $147.08 |
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 |
Brand New Day Classic Choice for Medi-Medi (HMO)
|
$35.50 |
$405 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
25% | n/a | None | $147.08 |
Browse Plan Formulary |
Brand New Day Classic Choice for Medi-Medi (HMO)
|
$35.50 |
$405 | to be determined | 4 |
Non-Preferred Drug |
25% | n/a | None | $147.08 |
Browse Plan Formulary |
Brand New Day Dual Coverage (HMO SNP)
|
$35.50 |
$405 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
25% | n/a | None | $147.08 |
Browse Plan Formulary |
Brand New Day Dual Coverage (HMO SNP)
|
$35.50 |
$405 | to be determined | 4 |
Non-Preferred Drug |
25% | n/a | None | $147.08 |
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 | 4 |
Non-Preferred Drug |
25% | n/a | None | $147.08 |
Browse Plan Formulary |
Brand New Day Embrace Choice for Medi-Medi (HMO SNP)
|
$35.50 |
$405 | to be determined | 4 |
Non-Preferred Drug |
25% | n/a | None | $147.08 |
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 |
Brand New Day Harmony Choice for Medi-Medi (HMO SNP)
|
$35.50 |
$405 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
25% | n/a | None | $147.08 |
Browse Plan Formulary |
Brand New Day Harmony Choice for Medi-Medi (HMO SNP)
|
$35.50 |
$405 | to be determined | 4 |
Non-Preferred Drug |
25% | n/a | None | $147.08 |
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 | 4 |
Non-Preferred Drug |
25% | n/a | None | $147.08 |
Browse Plan Formulary |
Brand New Day In Control Choice for Medi-Medi (HMO SNP)
|
$35.50 |
$405 | to be determined | 4 |
Non-Preferred Drug |
25% | n/a | None | $147.08 |
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 | $135.15 |
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 | None | $43.65 |
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 |
Central Health Premier Plan (HMO)
|
$35.50 |
$405 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
25% | n/a | None | $53.75 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$35.50 |
$405 | to be determined | 4 |
Non-Preferred Drug |
25% | n/a | None | $53.75 |
Browse Plan Formulary |
Coordinated Choice Plan (HMO)
|
$35.50 |
$405 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
25% | n/a | None | $145.96 |
Browse Plan Formulary |
Coordinated Choice Plan (HMO)
|
$35.50 |
$405 | to be determined | 2 |
Generic |
25% | n/a | None | $145.96 |
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 | $79.49 |
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 | $79.49 |
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 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 | $79.49 |
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 | $79.49 |
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 | $79.49 |
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 | $79.49 |
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 | $79.49 |
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 | $79.49 |
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 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 | $79.49 |
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 | $78.13 |
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 | $79.49 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$35.50 |
$240 | to be determined | 4 |
Non-Preferred Brand |
$100.00 | n/a | None | $79.49 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$35.50 |
$240 | to be determined | 4 |
Non-Preferred Brand |
$100.00 | n/a | None | $78.13 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$35.50 |
$240 | to be determined | 4 |
Non-Preferred Brand |
$100.00 | n/a | None | $79.49 |
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 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 | $79.49 |
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 | $79.49 |
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 | $48.72 |
Browse Plan Formulary |
PHP (HMO SNP)
|
$35.50 |
$405 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
25% | n/a | None | $144.88 |
Browse Plan Formulary |
PHP (HMO SNP)
|
$35.50 |
$405 | to be determined | 1 |
Generic |
25% | n/a | None | $144.88 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$35.50 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
25% | n/a | None | $116.56 |
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 | 2 |
Generic |
25% | n/a | None | $116.56 |
Browse Plan Formulary |
Traditional Plus-LA (HMO)
|
$35.50 |
$405 | to be determined | 4 |
Non-Preferred Drug |
25% | n/a | None | $40.78 |
Browse Plan Formulary |
VillageHealth (HMO-POS SNP)
|
$35.50 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
25% | n/a | None | $113.81 |
Browse Plan Formulary |
VillageHealth (HMO-POS SNP)
|
$35.50 |
$405 | to be determined | 2 |
Generic |
25% | n/a | None | $113.81 |
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 | S | $157.24 |
Browse Plan Formulary |