SUMATRIPTAN 6 MG/0.5 ML SYRNG Syringe [Sumavel DosePro System] (ml ) (NDC: 67457087905)
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 | Q:6 /30Days | $59.65 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Focus (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:6 /30Days | $59.65 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:6 /30Days | $59.65 |
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 | Q:6 /30Days | $59.65 |
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 | Q:6 /30Days | $59.65 |
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 |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:6 /30Days | $59.65 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:4 /30Days | $68.06 |
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 | Q:4 /30Days | $68.06 |
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 | Q:4 /30Days | $68.06 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:4 /30Days | $68.06 |
Browse Plan Formulary |
Alignment Health Plan Heart & Diabetes (HMO SNP)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$30.00 | $75.00 | None | $70.56 |
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 |
Alignment Health Plan Heart & Diabetes (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | $75.00 | None | $70.56 |
Browse Plan Formulary |
Alignment Health Plan My Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | $75.00 | None | $70.88 |
Browse Plan Formulary |
Alignment Health Plan My Choice (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$30.00 | $75.00 | None | $70.88 |
Browse Plan Formulary |
Alignment Health Plan Platinum (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$30.00 | $75.00 | None | $70.56 |
Browse Plan Formulary |
Alignment Health Plan Platinum (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | $75.00 | None | $70.56 |
Browse Plan Formulary |
Alignment Health Plan smartHMO (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | $75.00 | None | $70.56 |
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 |
Alignment Health Plan smartHMO (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$30.00 | $75.00 | None | $70.56 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $58.03 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $58.03 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $58.03 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $58.03 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Injectable Drugs |
25% | 25% | Q:8 /30Days | $63.70 |
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 |
5 |
Injectable Drugs |
25% | 25% | Q:8 /30Days | $63.70 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 |
to be determined |
5 |
Injectable Drugs |
31% | 31% | Q:8 /30Days | $63.70 |
Browse Plan Formulary |
Brand New Day Bridges Care Plan (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$75.00 | $225.00 | Q:4 /28Days | $60.41 |
Browse Plan Formulary |
Brand New Day Bridges Care Plan (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $225.00 | Q:4 /28Days | $60.41 |
Browse Plan Formulary |
Brand New Day Classic Care I Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | Q:4 /28Days | $60.41 |
Browse Plan Formulary |
Brand New Day Classic Care I Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | Q:4 /28Days | $60.41 |
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 |
Brand New Day Classic Care II Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | Q:4 /28Days | $60.41 |
Browse Plan Formulary |
Brand New Day Classic Care II Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | Q:4 /28Days | $60.41 |
Browse Plan Formulary |
Brand New Day Embrace Care Plan (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | Q:4 /28Days | $60.41 |
Browse Plan Formulary |
Brand New Day Embrace Care Plan (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | Q:4 /28Days | $60.41 |
Browse Plan Formulary |
Brand New Day Embrace Care Plan (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | Q:4 /28Days | $60.41 |
Browse Plan Formulary |
Brand New Day Embrace Care Plan (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$85.00 | $255.00 | Q:4 /28Days | $60.41 |
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 |
Brand New Day Harmony Care Plan (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$9.00 | $18.00 | Q:4 /28Days | $60.41 |
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 | Q:4 /28Days | $60.41 |
Browse Plan Formulary |
Central Health Focus Plan (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$75.00 | $150.00 | Q:4 /28Days | $59.42 |
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 | $150.00 | Q:4 /28Days | $59.42 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO SNP)
|
$0.00 |
$415 |
to be determined |
4 |
Non-Preferred Drug |
25% | 25% | Q:4 /28Days | $59.42 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$75.00 | $150.00 | Q:4 /28Days | $59.42 |
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 Medicare Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $150.00 | Q:4 /28Days | $59.42 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$0.00 | $0.00 | Q:6 /30Days | $63.53 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | Q:6 /30Days | $63.53 |
Browse Plan Formulary |
Easy Choice Freedom Plan (HMO SNP)
|
$0.00 |
$415 |
to be determined |
4 |
Non-Preferred Drug |
50% | 50% | Q:6 /30Days | $63.53 |
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 | Q:5 /30Days | $72.21 |
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 | Q:5 /30Days | $73.45 |
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 |
2 |
Generic |
$10.00 | $20.00 | None | $72.35 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$10.00 | $20.00 | None | $72.35 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $20.00 | None | $72.35 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $20.00 | None | $72.35 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$10.00 | $20.00 | None | $72.35 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$10.00 | $20.00 | None | $72.35 |
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 |
2 |
Generic |
$10.00 | $20.00 | None | $72.35 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $20.00 | None | $72.35 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:6 /30Days | $63.54 |
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 | Q:6 /30Days | $63.54 |
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 | $30.00 | None | $67.67 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$15.00 | $30.00 | None | $67.67 |
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 |
L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
2 |
Brand Drugs |
0% | 0% | Q:5 /30Days | $70.47 |
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% | Q:5 /30Days | $70.47 |
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% | Q:6 /30Days | $63.77 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Generic Drugs |
0% | 0% | Q:6 /30Days | $63.77 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$0.00 |
$415 |
to be determined |
4 |
Non-Preferred Drug |
33% | 33% | Q:6 /30Days | $38.14 |
Browse Plan Formulary |
PHP (HMO SNP)
|
$0.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
25% | n/a | Q:4 /28Days | $59.42 |
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 |
PHP (HMO SNP)
|
$0.00 |
$415 |
to be determined |
1 |
Generic |
25% | n/a | Q:4 /28Days | $59.42 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $68.64 |
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 | None | $68.64 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $68.64 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $68.64 |
Browse Plan Formulary |
SCAN Classic II (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $68.64 |
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)
|
$0.00 |
$415 |
to be determined |
4 |
Non-Preferred Drug |
25% | 25% | None | $51.60 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
|
$0.00 |
$415 |
to be determined |
4 |
Non-Preferred Drug |
25% | 25% | None | $68.64 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $51.60 |
Browse Plan Formulary |
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 | None | $51.60 |
Browse Plan Formulary |
SCAN Prime (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $68.64 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$17.00 | $34.00 | None | $67.67 |
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 |
Easy Choice Rx (HMO)
|
$12.00 |
$415 |
to be determined |
2 |
Generic |
$20.00 | $0.00 | Q:6 /30Days | $63.53 |
Browse Plan Formulary |
Easy Choice Rx (HMO)
|
$12.00 |
$415 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | Q:6 /30Days | $63.53 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$12.50 |
$0 |
to be determined |
2 |
Generic |
$15.00 | $30.00 | None | $67.67 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$12.50 |
$0 |
to be determined |
2 |
Generic |
$15.00 | $30.00 | None | $67.67 |
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% | Q:6 /30Days | $38.14 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$16.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $20.00 | None | $72.35 |
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. |
2 |
Generic |
$10.00 | $20.00 | None | $72.35 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Assure (HMO)
|
$16.10 |
$415 |
to be determined |
4 |
All Formulary Drugs |
25% | 25% | Q:6 /30Days | $59.65 |
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% | Q:6 /30Days | $59.65 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Premier (HMO)
|
$18.30 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:6 /30Days | $59.65 |
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 | Q:6 /30Days | $59.65 |
Browse Plan Formulary |
Easy Choice Freedom Plan (HMO SNP)
|
$19.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | Q:6 /30Days | $63.53 |
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 Prime (HMO)
|
$25.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $68.64 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$26.30 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $0.00 | Q:6 /30Days | $63.53 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$26.30 |
$415 |
to be determined |
2 |
Generic |
$20.00 | $0.00 | Q:6 /30Days | $63.53 |
Browse Plan Formulary |
Alignment Health Plan CalPlus (HMO)
|
$30.50 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | 25% | None | $70.71 |
Browse Plan Formulary |
Alignment Health Plan CalPlus (HMO)
|
$30.50 |
$415 |
to be determined |
3 |
Preferred Brand |
25% | 25% | None | $70.71 |
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 | None | $68.64 |
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 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:6 /30Days | $63.40 |
Browse Plan Formulary |
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 | Q:6 /30Days | $63.40 |
Browse Plan Formulary |
SCAN Connections (HMO SNP)
|
$33.40 |
$415 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | 25% | None | $51.60 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$34.80 |
$415 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $58.03 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$34.80 |
$415 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $58.03 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$34.80 |
$415 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $58.03 |
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 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $58.03 |
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 |
4 |
Non-Preferred Drug |
25% | 25% | Q:4 /28Days | $60.41 |
Browse Plan Formulary |
Brand New Day Bridges Choice Medi-Medi Plan (HMO SNP)
|
$34.80 |
$415 |
to be determined |
4 |
Non-Preferred Drug |
25% | 25% | Q:4 /28Days | $60.41 |
Browse Plan Formulary |
Brand New Day Classic Choice Medi-Medi Plan (HMO)
|
$34.80 |
$415 |
to be determined |
4 |
Non-Preferred Drug |
25% | 25% | Q:4 /28Days | $60.41 |
Browse Plan Formulary |
Brand New Day Classic Choice Medi-Medi Plan (HMO)
|
$34.80 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | Q:4 /28Days | $60.41 |
Browse Plan Formulary |
Brand New Day Dual Access Plan (HMO SNP)
|
$34.80 |
$415 |
to be determined |
4 |
Non-Preferred Drug |
25% | 25% | Q:4 /28Days | $60.41 |
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 |
Brand New Day Dual Access Plan (HMO SNP)
|
$34.80 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | Q:4 /28Days | $60.41 |
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 |
4 |
Non-Preferred Drug |
25% | 25% | Q:4 /28Days | $60.41 |
Browse Plan Formulary |
Brand New Day Embrace Choice Medi-Medi Plan (HMO SNP)
|
$34.80 |
$415 |
to be determined |
4 |
Non-Preferred Drug |
25% | 25% | Q:4 /28Days | $60.41 |
Browse Plan Formulary |
Brand New Day Embrace Choice Medi-Medi Plan (HMO SNP)
|
$34.80 |
$415 |
to be determined |
4 |
Non-Preferred Drug |
25% | 25% | Q:4 /28Days | $60.41 |
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 |
4 |
Non-Preferred Drug |
25% | 25% | Q:4 /28Days | $60.41 |
Browse Plan Formulary |
Brand New Day Harmony Choice Plan (HMO SNP)
|
$34.80 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | Q:4 /28Days | $60.41 |
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 |
Brand New Day Harmony Choice Plan (HMO SNP)
|
$34.80 |
$415 |
to be determined |
4 |
Non-Preferred Drug |
25% | 25% | Q:4 /28Days | $60.41 |
Browse Plan Formulary |
Brand New Day Select Care Plan (HMO SNP)
|
$34.80 |
$415 |
to be determined |
4 |
Non-Preferred Drug |
25% | 25% | Q:4 /28Days | $60.41 |
Browse Plan Formulary |
Brand New Day Select Care Plan (HMO SNP)
|
$34.80 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | Q:4 /28Days | $60.41 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO SNP)
|
$34.80 |
$415 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | 25% | Q:4 /28Days | $59.42 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$34.80 |
$415 |
to be determined |
4 |
Non-Preferred Drug |
25% | 25% | Q:4 /28Days | $59.42 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$34.80 |
$415 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | 25% | Q:4 /28Days | $59.42 |
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 |
Health Net Seniority Plus Amber I (HMO SNP)
|
$34.80 |
$320 |
to be determined |
2 |
Generic |
$20.00 | $60.00 | None | $71.26 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$34.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $60.00 | None | $71.26 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 |
to be determined |
2 |
Generic |
$20.00 | $60.00 | None | $71.26 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $60.00 | None | $71.26 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $60.00 | None | $76.76 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 |
to be determined |
2 |
Generic |
$20.00 | $60.00 | None | $71.26 |
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 |
2 |
Generic |
$20.00 | $60.00 | None | $71.26 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 |
to be determined |
2 |
Generic |
$20.00 | $60.00 | None | $76.76 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $60.00 | None | $76.76 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 |
to be determined |
2 |
Generic |
$20.00 | $60.00 | None | $71.26 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $60.00 | None | $71.26 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 |
to be determined |
2 |
Generic |
$20.00 | $60.00 | None | $76.76 |
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 |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 |
to be determined |
2 |
Generic |
$20.00 | $60.00 | None | $71.26 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $60.00 | None | $71.26 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$34.80 |
$285 |
to be determined |
2 |
Generic |
$20.00 | $60.00 | None | $71.26 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$34.80 |
$285 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $60.00 | None | $71.26 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier II (HMO)
|
$34.80 |
$280 |
to be determined |
2 |
Generic |
$20.00 | $60.00 | None | $71.26 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier II (HMO)
|
$34.80 |
$280 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $60.00 | None | $71.26 |
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)
|
$34.80 |
$415 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | 25% | None | $68.64 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$34.80 |
$415 |
to be determined |
4 |
Non-Preferred Drug |
25% | 25% | None | $51.96 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$34.80 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | None | $51.96 |
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 | $67.67 |
Browse Plan Formulary |
VillageHealth (HMO-POS SNP)
|
$34.80 |
$415 |
to be determined |
4 |
Non-Preferred Drug |
25% | 25% | None | $68.64 |
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% | None | $68.64 |
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 Choice Plan (PPO)
|
$40.90 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:4 /30Days | $68.06 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$73.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:4 /30Days | $68.06 |
Browse Plan Formulary |