Nitroglycerin 5mg/mL 25 VIAL, SINGLE-DOSE in 1 TRAY / 10 mL in 1 VIAL, SINGLE-DOSE (25 VIAL, SINGLE-DOSE ) (NDC: 00517481025)
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 | $306.16 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $306.16 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $306.16 |
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 | $306.16 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $344.50 |
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 |
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 | $344.50 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $344.50 |
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 | $344.50 |
Browse Plan Formulary |
Anthem Breathe (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$7.50 | n/a | P | $285.41 |
Browse Plan Formulary |
Anthem Breathe (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$7.50 | n/a | P | $285.41 |
Browse Plan Formulary |
Anthem Connect (HMO SNP)
|
$0.00 |
$405* |
to be determined |
2* |
Generic |
$0.00 | n/a | P | $285.41 |
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* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$0.00 | n/a | P | $285.41 |
Browse Plan Formulary |
Anthem Diabetes (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$7.50 | n/a | P | $285.41 |
Browse Plan Formulary |
Anthem Diabetes (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$7.50 | n/a | P | $285.41 |
Browse Plan Formulary |
Anthem ESRD (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$7.50 | n/a | P | $285.41 |
Browse Plan Formulary |
Anthem ESRD (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$7.50 | n/a | P | $285.41 |
Browse Plan Formulary |
Anthem Heart (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$7.50 | n/a | P | $285.41 |
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 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$7.50 | n/a | P | $285.41 |
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 | $284.86 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | n/a | P | $284.86 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | n/a | P | $284.86 |
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 | $284.86 |
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 | P | $285.41 |
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 |
to be determined |
2 |
Generic |
$14.50 | n/a | P | $285.41 |
Browse Plan Formulary |
Anthem Touch (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$9.50 | n/a | P | $285.41 |
Browse Plan Formulary |
Anthem Touch (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$9.50 | n/a | P | $285.41 |
Browse Plan Formulary |
Anthem Value Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$9.50 | n/a | P | $285.41 |
Browse Plan Formulary |
Anthem Value Plus (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$9.50 | n/a | P | $285.41 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Injectable Drugs |
30% | n/a | None | $324.67 |
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 |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Injectable Drugs |
30% | n/a | None | $324.67 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Injectable Drugs |
31% | n/a | None | $324.67 |
Browse Plan Formulary |
Brand New Day Bridges Drug Savings (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$8.00 | n/a | None | $297.29 |
Browse Plan Formulary |
Brand New Day Bridges Drug Savings (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$8.00 | n/a | None | $297.29 |
Browse Plan Formulary |
Brand New Day Classic Care Drug Savings (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$8.00 | n/a | None | $297.29 |
Browse Plan Formulary |
Brand New Day Classic Care Drug Savings (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$8.00 | n/a | None | $297.29 |
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. |
2 |
Generic |
$8.00 | n/a | None | $297.29 |
Browse Plan Formulary |
Brand New Day Embrace Care Drug Savings (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$8.00 | n/a | None | $297.29 |
Browse Plan Formulary |
Brand New Day Harmony Drug Savings (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$9.00 | n/a | None | $297.29 |
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 | $297.29 |
Browse Plan Formulary |
Brand New Day In Control Drug Savings (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$8.00 | n/a | None | $297.29 |
Browse Plan Formulary |
Brand New Day In Control Drug Savings (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$8.00 | n/a | None | $297.29 |
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 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | n/a | P | $127.24 |
Browse Plan Formulary |
Central Health Focus Plan (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$75.00 | n/a | P | $127.24 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO SNP)
|
$0.00 |
$405 |
to be determined |
4 |
Non-Preferred Drug |
25% | n/a | P | $127.24 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$75.00 | n/a | P | $127.24 |
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 | $127.24 |
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 | $327.28 |
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 | $327.28 |
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 | $327.28 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$10.00 | $0.00 | None | $412.72 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | None | $412.72 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$15.00 | n/a | None | $285.61 |
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 | $285.61 |
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 Balance (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$2.00 | n/a | None | $286.13 |
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 | $286.13 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | n/a | None | $286.13 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$5.00 | n/a | None | $286.13 |
Browse Plan Formulary |
SCAN Classic II (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$5.00 | n/a | None | $286.13 |
Browse Plan Formulary |
SCAN Connections (HMO SNP)
|
$0.00 |
$405 |
to be determined |
2 |
Generic |
25% | n/a | None | $286.13 |
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 |
SCAN Connections at Home (HMO SNP)
|
$0.00 |
$405 |
to be determined |
2 |
Generic |
25% | n/a | None | $286.13 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$5.00 | n/a | None | $286.13 |
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 | $286.13 |
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 | $285.61 |
Browse Plan Formulary |
Traditional-LA (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$90.00 | n/a | P | $118.01 |
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 | $285.61 |
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 | $285.61 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$16.30 |
$405* |
to be determined |
2* |
Generic |
$19.00 | $0.00 | None | $412.72 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$16.30 |
$405* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$19.00 | $0.00 | None | $412.72 |
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 | $306.16 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 3 (HMO)
|
$17.30 |
$405 |
to be determined |
4 |
Tier 4 |
25% | n/a | None | $306.16 |
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 | $286.13 |
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 |
AARP MedicareComplete SecureHorizons Premier (HMO)
|
$26.70 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $306.16 |
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 | $306.16 |
Browse Plan Formulary |
SCAN Connections (HMO SNP)
|
$30.00 |
$405 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
25% | n/a | None | $286.13 |
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 | $285.61 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$32.30 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $344.50 |
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 | P | $285.41 |
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 |
to be determined |
2 |
Tier 2 |
25% | n/a | P | $285.41 |
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 | $286.13 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$35.50 |
$405 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | n/a | P | $284.86 |
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 | $284.86 |
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 |
2 |
Generic |
25% | n/a | None | $297.29 |
Browse Plan Formulary |
Brand New Day Bridges Choice for Medi-Medi (HMO SNP)
|
$35.50 |
$405 |
to be determined |
2 |
Generic |
25% | n/a | None | $297.29 |
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 |
to be determined |
2 |
Generic |
25% | n/a | None | $297.29 |
Browse Plan Formulary |
Brand New Day Classic Choice for Medi-Medi (HMO)
|
$35.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | n/a | None | $297.29 |
Browse Plan Formulary |
Brand New Day Dual Coverage (HMO SNP)
|
$35.50 |
$405* |
to be determined |
2* |
Generic |
0% | n/a | None | $297.29 |
Browse Plan Formulary |
Brand New Day Dual Coverage (HMO SNP)
|
$35.50 |
$405* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
0% | n/a | None | $297.29 |
Browse Plan Formulary |
Brand New Day Embrace Choice for Medi-Medi (HMO SNP)
|
$35.50 |
$405 |
to be determined |
2 |
Generic |
25% | n/a | None | $297.29 |
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 |
2 |
Generic |
25% | n/a | None | $297.29 |
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 |
2 |
Generic |
25% | n/a | None | $297.29 |
Browse Plan Formulary |
Brand New Day Harmony Choice for Medi-Medi (HMO SNP)
|
$35.50 |
$405 |
to be determined |
2 |
Generic |
25% | n/a | None | $297.29 |
Browse Plan Formulary |
Brand New Day In Control Choice for Medi-Medi (HMO SNP)
|
$35.50 |
$405 |
to be determined |
2 |
Generic |
25% | n/a | None | $297.29 |
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 |
2 |
Generic |
25% | n/a | None | $297.29 |
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 | $127.24 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$35.50 |
$405 |
to be determined |
4 |
Non-Preferred Drug |
25% | n/a | P | $127.24 |
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 |
Central Health Premier Plan (HMO)
|
$35.50 |
$405 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | n/a | P | $127.24 |
Browse Plan Formulary |
PHP (HMO SNP)
|
$35.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
25% | n/a | None | $302.62 |
Browse Plan Formulary |
PHP (HMO SNP)
|
$35.50 |
$405 |
to be determined |
1 |
Generic |
25% | n/a | None | $302.62 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$35.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | n/a | None | $286.13 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$35.50 |
$405 |
to be determined |
2 |
Generic |
25% | n/a | None | $286.13 |
Browse Plan Formulary |
Traditional Plus-LA (HMO)
|
$35.50 |
$405 |
to be determined |
4 |
Non-Preferred Drug |
25% | n/a | P | $118.01 |
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 |
VillageHealth (HMO-POS SNP)
|
$35.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | n/a | None | $286.13 |
Browse Plan Formulary |
VillageHealth (HMO-POS SNP)
|
$35.50 |
$405 |
to be determined |
2 |
Generic |
25% | n/a | None | $286.13 |
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 | None | $344.50 |
Browse Plan Formulary |