PERFOROMIST 20MCG/2ML VIAL NEBULIZER (60 X 2ML CRTN) (NDC: 49502060561)
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 |
AARP MedicareComplete SecureHorizons Focus (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:120 /30Days | $1,023.58 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Focus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:120 /30Days | $1,023.58 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:120 /30Days | $1,023.58 |
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 Q:120 /30Days | $1,023.58 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:120 /30Days | $1,023.58 |
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 2 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:120 /30Days | $1,023.58 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $1,021.88 |
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:120 /30Days | $1,021.88 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $1,016.62 |
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:120 /30Days | $1,016.62 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 | to be determined | 5 |
Specialty Tier |
33% | n/a | P | $1,032.00 |
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 |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $1,032.00 |
Browse Plan Formulary |
Easy Choice Freedom Plan (HMO SNP)
|
$0.00 |
$415 | to be determined | 5 |
Specialty Tier |
25% | n/a | P | $1,032.00 |
Browse Plan Formulary |
Golden State (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:120 /30Days | $1,056.48 |
Browse Plan Formulary |
Golden State (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:120 /30Days | $1,084.66 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$90.00 | $260.00 | P Q:4 /1Days | $1,044.51 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$90.00 | $260.00 | P Q:4 /1Days | $1,044.51 |
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 Drug |
$90.00 | $260.00 | P Q:4 /1Days | $1,042.52 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$90.00 | $260.00 | P Q:4 /1Days | $1,042.52 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$90.00 | $260.00 | P Q:4 /1Days | $1,044.51 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$90.00 | $260.00 | P Q:4 /1Days | $1,042.52 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$90.00 | $260.00 | P Q:4 /1Days | $1,044.55 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$90.00 | $260.00 | P Q:4 /1Days | $1,044.55 |
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 | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | P | $1,021.40 |
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 | P | $1,021.40 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Brand |
$100.00 | $200.00 | P | $1,047.21 |
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 | $200.00 | P | $1,047.21 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$95.00 | $275.00 | P | $1,021.52 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $275.00 | P | $1,021.52 |
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 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $275.00 | P | $1,016.08 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$95.00 | $275.00 | P | $1,016.08 |
Browse Plan Formulary |
SCAN Classic II (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$95.00 | $275.00 | P | $1,016.08 |
Browse Plan Formulary |
SCAN Connections (HMO SNP)
|
$0.00 |
$415 | to be determined | 4 |
Non-Preferred Drug |
25% | 25% | P | $1,018.12 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
|
$0.00 |
$415 | to be determined | 4 |
Non-Preferred Drug |
25% | 25% | P | $1,016.08 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $1,022.71 |
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 |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | P | $1,022.71 |
Browse Plan Formulary |
SCAN Prime (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$95.00 | $275.00 | P | $1,016.08 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Brand |
$100.00 | $200.00 | P | $1,047.21 |
Browse Plan Formulary |
Easy Choice Rx (HMO)
|
$12.00 |
$415 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | n/a | P | $1,032.00 |
Browse Plan Formulary |
Easy Choice Rx (HMO)
|
$12.00 |
$415 | to be determined | 5 |
Specialty Tier |
25% | n/a | P | $1,032.00 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$12.50 |
$0 | to be determined | 4 |
Non-Preferred Brand |
$100.00 | $200.00 | P | $1,047.21 |
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 |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$12.50 |
$0 | to be determined | 4 |
Non-Preferred Brand |
$100.00 | $200.00 | P | $1,047.21 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$16.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$90.00 | $260.00 | P Q:4 /1Days | $1,044.51 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$16.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$90.00 | $260.00 | P Q:4 /1Days | $1,042.52 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Assure (HMO)
|
$16.10 |
$415 | No additional gap coverage, only the Donut Hole Discount | 4 |
All Formulary Drugs |
25% | 25% | P Q:120 /30Days | $1,035.55 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Assure (HMO)
|
$16.10 |
$415 | to be determined | 4 |
All Formulary Drugs |
25% | 25% | P Q:120 /30Days | $1,035.55 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Premier (HMO)
|
$18.30 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:120 /30Days | $1,023.58 |
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)
|
$18.30 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:120 /30Days | $1,023.58 |
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 | P | $1,032.00 |
Browse Plan Formulary |
SCAN Prime (HMO)
|
$25.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $275.00 | P | $1,016.08 |
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 | P | $1,032.00 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$26.30 |
$415 | to be determined | 5 |
Specialty Tier |
25% | n/a | P | $1,032.00 |
Browse Plan Formulary |
SCAN Classic II (HMO)
|
$32.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $275.00 | P | $1,016.08 |
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 |
Humana Value Plus H5619-037 (HMO)
|
$33.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $1,021.40 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$33.30 |
$415 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $1,021.40 |
Browse Plan Formulary |
SCAN Connections (HMO SNP)
|
$33.40 |
$415 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
25% | 25% | P | $1,018.12 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$34.80 |
$415 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $1,021.88 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$34.80 |
$415 | to be determined | 5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $1,021.88 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$34.80 |
$415 | to be determined | 5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $1,016.62 |
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 Extra (HMO)
|
$34.80 |
$415 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $1,016.62 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$34.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /1Days | $1,032.00 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$34.80 |
$320 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /1Days | $1,032.00 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /1Days | $1,032.00 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /1Days | $1,032.00 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /1Days | $1,032.00 |
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 |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /1Days | $1,032.00 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /1Days | $1,032.00 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /1Days | $1,032.00 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /1Days | $1,032.00 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /1Days | $1,032.00 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /1Days | $1,032.00 |
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 |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /1Days | $1,032.00 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /1Days | $1,032.00 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /1Days | $1,032.00 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$34.80 |
$285 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /1Days | $1,032.00 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$34.80 |
$285 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /1Days | $1,032.00 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier II (HMO)
|
$34.80 |
$280 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /1Days | $1,032.00 |
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 |
Health Net Seniority Plus Sapphire Premier II (HMO)
|
$34.80 |
$280 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:4 /1Days | $1,032.00 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
|
$34.80 |
$415 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
25% | 25% | P | $1,016.08 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$34.80 |
$415 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
25% | 25% | P | $1,025.06 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$34.80 |
$415 | to be determined | 4 |
Non-Preferred Drug |
25% | 25% | P | $1,025.06 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$34.80 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$100.00 | $200.00 | P | $1,047.21 |
Browse Plan Formulary |
VillageHealth (HMO-POS SNP)
|
$34.80 |
$415 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
25% | 25% | P | $1,021.52 |
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)
|
$34.80 |
$415 | to be determined | 4 |
Non-Preferred Drug |
25% | 25% | P | $1,021.52 |
Browse Plan Formulary |