SIVEXTRO 200 MG TABLET (6.000 EA ) (NDC: 67919004102)
2019 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 |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $11,476.20 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $11,476.20 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $11,476.20 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $11,476.20 |
Browse Plan Formulary |
Alignment Health Plan Heart & Diabetes (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $11,236.90 |
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 |
Alignment Health Plan Heart & Diabetes (HMO SNP)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | P | $11,236.90 |
Browse Plan Formulary |
Alignment Health Plan My Choice (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $11,264.70 |
Browse Plan Formulary |
Alignment Health Plan My Choice (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | P | $11,264.70 |
Browse Plan Formulary |
Alignment Health Plan Platinum (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $11,236.90 |
Browse Plan Formulary |
Alignment Health Plan Platinum (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | P | $11,236.90 |
Browse Plan Formulary |
Alignment Health Plan smartHMO (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $11,179.80 |
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 |
Alignment Health Plan smartHMO (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | P | $11,179.80 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:6 /30Days | $10,900.40 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | P Q:6 /30Days | $10,900.40 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:6 /30Days | $10,957.50 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | P Q:6 /30Days | $10,957.50 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 6 |
Specialty Tier |
33% | n/a | P Q:6 /30Days | $11,026.70 |
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 | to be determined | 6 |
Specialty Tier |
33% | n/a | P Q:6 /30Days | $11,026.70 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 | to be determined | 6 |
Specialty Tier |
33% | n/a | P Q:6 /30Days | $11,026.70 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $11,369.60 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $11,369.60 |
Browse Plan Formulary |
Easy Choice Freedom Plan (HMO SNP)
|
$0.00 |
$415 | to be determined | 5 |
Specialty Tier |
25% | n/a | None | $11,369.60 |
Browse Plan Formulary |
Golden State (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | 33% | Q:6 /30Days | $11,510.40 |
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 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | 33% | Q:6 /30Days | $11,685.90 |
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% | 0% | None | $11,106.60 |
Browse Plan Formulary |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Brand Drugs |
0% | 0% | None | $11,106.60 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $11,419.80 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $11,342.80 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $11,419.80 |
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 Gold Select (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $11,342.80 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $11,419.80 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $11,342.80 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $11,425.20 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $11,425.20 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | Q:6 /28Days | $11,815.20 |
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 |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | Q:6 /28Days | $11,815.20 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | 33% | None | $11,552.60 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | 33% | None | $11,552.60 |
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% | 0% | P Q:6 /6Days | $11,181.10 |
Browse Plan Formulary |
L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Brand Drugs |
0% | 0% | P Q:6 /6Days | $11,181.10 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Brand Drugs |
0% | 0% | None | $11,106.60 |
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 Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Brand Drugs |
0% | 0% | None | $11,106.60 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$0.00 |
$415 | to be determined | 5 |
Specialty Tier |
25% | n/a | None | $11,106.60 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $10,900.40 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $10,900.40 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $10,957.50 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $10,957.50 |
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 |
SCAN Classic II (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $10,957.50 |
Browse Plan Formulary |
SCAN Connections (HMO SNP)
|
$0.00 |
$415 | to be determined | 5 |
Specialty Tier |
25% | n/a | None | $10,977.50 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
|
$0.00 |
$415 | to be determined | 5 |
Specialty Tier |
25% | n/a | None | $10,957.50 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $10,923.10 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $10,923.10 |
Browse Plan Formulary |
SCAN Prime (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $10,957.50 |
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 |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | 33% | None | $11,297.40 |
Browse Plan Formulary |
Easy Choice Rx (HMO)
|
$12.00 |
$415 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | n/a | None | $11,369.60 |
Browse Plan Formulary |
Easy Choice Rx (HMO)
|
$12.00 |
$415 | to be determined | 5 |
Specialty Tier |
25% | n/a | None | $11,369.60 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$12.50 |
$0 | to be determined | 5 |
Specialty Tier |
33% | 33% | None | $11,297.40 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$12.50 |
$0 | to be determined | 5 |
Specialty Tier |
33% | 33% | None | $11,297.40 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$15.20 |
$415 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $11,106.60 |
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)
|
$16.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $11,419.80 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$16.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $11,342.80 |
Browse Plan Formulary |
Easy Choice Freedom Plan (HMO SNP)
|
$19.00 |
$415 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $11,369.60 |
Browse Plan Formulary |
SCAN Prime (HMO)
|
$25.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $10,957.50 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$26.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $11,369.60 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$26.30 |
$415 | to be determined | 5 |
Specialty Tier |
25% | n/a | None | $11,369.60 |
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)
|
$30.50 |
$415 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P | $11,302.10 |
Browse Plan Formulary |
Alignment Health Plan CalPlus (HMO)
|
$30.50 |
$415 | to be determined | 5 |
Specialty Tier |
25% | n/a | P | $11,302.10 |
Browse Plan Formulary |
SCAN Classic II (HMO)
|
$32.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $10,957.50 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$33.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | Q:6 /28Days | $11,815.20 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$33.30 |
$415 | to be determined | 5 |
Specialty Tier |
25% | n/a | Q:6 /28Days | $11,815.20 |
Browse Plan Formulary |
SCAN Connections (HMO SNP)
|
$33.40 |
$415 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | n/a | None | $10,977.50 |
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 |
Anthem MediBlue Coordination Plus (HMO)
|
$34.80 |
$415 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | n/a | P Q:6 /30Days | $10,900.40 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$34.80 |
$415 | to be determined | 5 |
Specialty Tier |
25% | n/a | P Q:6 /30Days | $10,900.40 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$34.80 |
$415 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | n/a | P Q:6 /30Days | $10,957.50 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$34.80 |
$415 | to be determined | 5 |
Specialty Tier |
25% | n/a | P Q:6 /30Days | $10,957.50 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$34.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
26% | n/a | None | $11,369.60 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$34.80 |
$320 | to be determined | 5 |
Specialty Tier |
26% | n/a | None | $11,369.60 |
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)
|
$34.80 |
$300 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
27% | n/a | None | $11,369.60 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
27% | n/a | None | $11,369.60 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
27% | n/a | None | $11,369.60 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 | to be determined | 5 |
Specialty Tier |
27% | n/a | None | $11,369.60 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 | to be determined | 5 |
Specialty Tier |
27% | n/a | None | $11,369.60 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 | to be determined | 5 |
Specialty Tier |
27% | n/a | None | $11,369.60 |
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)
|
$34.80 |
$340 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
26% | n/a | None | $11,369.60 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
26% | n/a | None | $11,369.60 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
26% | n/a | None | $11,369.60 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 | to be determined | 5 |
Specialty Tier |
26% | n/a | None | $11,369.60 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 | to be determined | 5 |
Specialty Tier |
26% | n/a | None | $11,369.60 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 | to be determined | 5 |
Specialty Tier |
26% | n/a | None | $11,369.60 |
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)
|
$34.80 |
$285 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
27% | n/a | None | $11,369.60 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$34.80 |
$285 | to be determined | 5 |
Specialty Tier |
27% | n/a | None | $11,369.60 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier II (HMO)
|
$34.80 |
$280 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
27% | n/a | None | $11,369.60 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier II (HMO)
|
$34.80 |
$280 | to be determined | 5 |
Specialty Tier |
27% | n/a | None | $11,369.60 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
|
$34.80 |
$415 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | n/a | None | $10,957.50 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$34.80 |
$415 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $10,954.00 |
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 |
SCAN Plus (HMO)
|
$34.80 |
$415 | to be determined | 5 |
Specialty Tier |
25% | n/a | None | $10,954.00 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$34.80 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | 33% | None | $11,297.40 |
Browse Plan Formulary |
VillageHealth (HMO-POS SNP)
|
$34.80 |
$415 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | None | $10,900.40 |
Browse Plan Formulary |
VillageHealth (HMO-POS SNP)
|
$34.80 |
$415 | to be determined | 5 |
Specialty Tier |
25% | n/a | None | $10,900.40 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$40.90 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | None | $11,473.60 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$73.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | None | $11,473.60 |
Browse Plan Formulary |