PREVALITE PACKET (60 EA ) (NDC: 00245003660)
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 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $119.26 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $119.26 |
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 | None | $104.77 |
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 | $106.23 |
Browse Plan Formulary |
Alignment Health Plan My Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $12.50 | None | $158.85 |
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 |
Alignment Health Plan Platinum (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $15.00 | None | $164.26 |
Browse Plan Formulary |
Anthem Breathe (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$9.50 | $19.00 | None | $108.31 |
Browse Plan Formulary |
Anthem Diabetes (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$9.50 | $19.00 | None | $108.31 |
Browse Plan Formulary |
Anthem ESRD (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$9.50 | $19.00 | None | $108.31 |
Browse Plan Formulary |
Anthem Heart (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$9.50 | $19.00 | None | $108.31 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$15.00 | $45.00 | None | $116.20 |
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 |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$15.00 | $45.00 | None | $108.31 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $10.00 | None | $108.31 |
Browse Plan Formulary |
Anthem StartSmart Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$14.50 | $29.00 | None | $126.26 |
Browse Plan Formulary |
Anthem Value Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$9.50 | $19.00 | None | $108.31 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $15.00 | None | $97.99 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $7.50 | None | $95.08 |
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 Bridges Care Plan (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$8.00 | $16.00 | None | $119.57 |
Browse Plan Formulary |
Brand New Day Classic Care I Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$8.00 | $16.00 | None | $119.57 |
Browse Plan Formulary |
Brand New Day Classic Care II Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $20.00 | None | $119.57 |
Browse Plan Formulary |
Brand New Day Embrace Care Plan (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$8.00 | $16.00 | None | $119.57 |
Browse Plan Formulary |
Brand New Day Embrace Care Plan (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$8.00 | $16.00 | None | $119.57 |
Browse Plan Formulary |
Brand New Day Harmony Care Plan (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$9.00 | $18.00 | None | $119.57 |
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. |
2 |
Generic |
$5.00 | $10.00 | None | $119.42 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $10.00 | None | $119.42 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | None | $101.31 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $126.17 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $126.17 |
Browse Plan Formulary |
Heart First (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$7.00 | $0.00 | None | $136.10 |
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 H5619-039 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $111.12 |
Browse Plan Formulary |
Humana Gold Plus H5619-039 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $111.07 |
Browse Plan Formulary |
IEHP DualChoice (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | 0% | None | $97.57 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage Inland Empire (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$15.00 | $30.00 | None | $141.39 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | 0% | None | $138.03 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$7.00 | $0.00 | None | $136.10 |
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 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$7.00 | $0.00 | None | $136.10 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $0.00 | None | $136.41 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$12.50 |
$0 |
to be determined |
2 |
Generic |
$15.00 | $30.00 | None | $144.89 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$15.20 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
33% | 33% | None | $138.03 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$16.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$5.00 | $10.00 | None | $126.17 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$16.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Preferred Generic |
$5.00 | $10.00 | None | $126.17 |
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 |
UnitedHealthcare MedicareComplete Assure (HMO)
|
$16.10 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
All Formulary Drugs |
25% | 25% | None | $127.12 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Premier (HMO)
|
$17.70 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $119.26 |
Browse Plan Formulary |
SCAN Prime (HMO)
|
$23.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$7.00 | $0.00 | None | $136.10 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$25.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $0.00 | None | $99.37 |
Browse Plan Formulary |
Alignment Health Plan CalPlus (HMO)
|
$30.50 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $30.00 | None | $164.55 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$33.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $111.00 |
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 Connections at Home (HMO SNP)
|
$33.30 |
$415 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
25% | 25% | None | $136.10 |
Browse Plan Formulary |
SCAN Connections (HMO SNP)
|
$33.40 |
$415 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
25% | 25% | None | $136.50 |
Browse Plan Formulary |
Anthem Connect Plus (HMO)
|
$34.70 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
2 |
All Formulary Drugs |
25% | 25% | None | $126.16 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$34.80 |
$415 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$8.00 | $24.00 | None | $112.93 |
Browse Plan Formulary |
Brand New Day Bridges Choice Medi-Medi Plan (HMO SNP)
|
$34.80 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | None | $119.57 |
Browse Plan Formulary |
Brand New Day Classic Choice Medi-Medi Plan (HMO)
|
$34.80 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | None | $119.57 |
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 Dual Access Plan (HMO SNP)
|
$34.80 |
$415* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
0% | 0% | None | $119.57 |
Browse Plan Formulary |
Brand New Day Embrace Choice Medi-Medi Plan (HMO SNP)
|
$34.80 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | None | $119.57 |
Browse Plan Formulary |
Brand New Day Embrace Choice Medi-Medi Plan (HMO SNP)
|
$34.80 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | None | $119.57 |
Browse Plan Formulary |
Brand New Day Harmony Choice Plan (HMO SNP)
|
$34.80 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | None | $119.57 |
Browse Plan Formulary |
Brand New Day Select Care Plan (HMO SNP)
|
$34.80 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | None | $119.57 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO SNP)
|
$34.80 |
$415* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$0.00 | $0.00 | None | $119.42 |
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 |
Central Health Premier Plan (HMO)
|
$34.80 |
$415* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$0.00 | $0.00 | None | $119.42 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$34.80 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $114.32 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $114.32 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $114.32 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $114.32 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $114.32 |
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 |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $114.32 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $114.32 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$34.80 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $114.32 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier II (HMO)
|
$34.80 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $114.32 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$34.80 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | None | $136.39 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$34.80 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$17.00 | $34.00 | None | $144.89 |
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 |
$370 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$3.00 | $9.00 | None | $136.10 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$81.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $106.23 |
Browse Plan Formulary |