ZALEPLON 10 MG CAPSULE (100.000 EA ) (NDC: 00093526901)
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. | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $39.66 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Focus (HMO)
|
$0.00 |
$0 | to be determined | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $39.66 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $39.66 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 | to be determined | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $39.66 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $39.66 |
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 | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $39.66 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $136.00 | P Q:60 /30Days | $45.49 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 | to be determined | 3 |
Preferred Brand |
$47.00 | $136.00 | P Q:60 /30Days | $45.49 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $136.00 | P Q:60 /30Days | $45.49 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 | to be determined | 3 |
Preferred Brand |
$47.00 | $136.00 | P Q:60 /30Days | $45.49 |
Browse Plan Formulary |
Alignment Health Plan Heart & Diabetes (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | $12.50 | None | $12.72 |
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 | 2 |
Generic |
$5.00 | $12.50 | None | $12.72 |
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 | $13.05 |
Browse Plan Formulary |
Alignment Health Plan My Choice (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$5.00 | $12.50 | None | $13.05 |
Browse Plan Formulary |
Alignment Health Plan Platinum (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$3.00 | $7.50 | None | $12.72 |
Browse Plan Formulary |
Alignment Health Plan Platinum (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$3.00 | $7.50 | None | $12.72 |
Browse Plan Formulary |
Alignment Health Plan smartHMO (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $25.00 | None | $12.22 |
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 | 2 |
Generic |
$10.00 | $25.00 | None | $12.22 |
Browse Plan Formulary |
Anthem Blue Cross Cal MediConnect (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Brand Drugs |
0% | 0% | P Q:60 /30Days | $15.55 |
Browse Plan Formulary |
Anthem Blue Cross Cal MediConnect (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Brand Drugs |
0% | 0% | P Q:60 /30Days | $15.55 |
Browse Plan Formulary |
Anthem Breathe (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$7.50 | $15.00 | P Q:60 /30Days | $15.43 |
Browse Plan Formulary |
Anthem Breathe (HMO SNP)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$7.50 | $15.00 | P Q:60 /30Days | $15.43 |
Browse Plan Formulary |
Anthem Care On Site (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$9.50 | $19.00 | P Q:60 /30Days | $15.43 |
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 Care On Site (HMO SNP)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$9.50 | $19.00 | P Q:60 /30Days | $15.43 |
Browse Plan Formulary |
Anthem Connect (HMO SNP)
|
$0.00 |
$415* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$0.00 | $0.00 | P Q:60 /30Days | $15.55 |
Browse Plan Formulary |
Anthem Connect (HMO SNP)
|
$0.00 |
$415* | to be determined | 2* |
Generic |
$0.00 | $0.00 | P Q:60 /30Days | $15.55 |
Browse Plan Formulary |
Anthem Diabetes (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$7.50 | $15.00 | P Q:60 /30Days | $15.43 |
Browse Plan Formulary |
Anthem Diabetes (HMO SNP)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$7.50 | $15.00 | P Q:60 /30Days | $15.43 |
Browse Plan Formulary |
Anthem ESRD (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$7.50 | $15.00 | P Q:60 /30Days | $15.43 |
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 ESRD (HMO SNP)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$7.50 | $15.00 | P Q:60 /30Days | $15.43 |
Browse Plan Formulary |
Anthem Heart (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$7.50 | $15.00 | P Q:60 /30Days | $15.43 |
Browse Plan Formulary |
Anthem Heart (HMO SNP)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$7.50 | $15.00 | P Q:60 /30Days | $15.43 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$15.00 | $45.00 | P Q:60 /30Days | $15.44 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$15.00 | $45.00 | P Q:60 /30Days | $15.44 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | $10.00 | P Q:60 /30Days | $15.56 |
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 |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$5.00 | $10.00 | P Q:60 /30Days | $15.56 |
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 | P Q:60 /30Days | $15.45 |
Browse Plan Formulary |
Anthem StartSmart Plus (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$14.50 | $29.00 | P Q:60 /30Days | $15.45 |
Browse Plan Formulary |
Anthem Value Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$9.50 | $19.00 | P Q:60 /30Days | $15.43 |
Browse Plan Formulary |
Anthem Value Plus (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$9.50 | $19.00 | P Q:60 /30Days | $15.43 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | $7.50 | P Q:2 /1Days | $10.93 |
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 | 2 |
Generic |
$5.00 | $7.50 | P Q:2 /1Days | $10.93 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$10.00 | $15.00 | P Q:2 /1Days | $10.93 |
Browse Plan Formulary |
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 | P Q:60 /30Days | $14.00 |
Browse Plan Formulary |
Brand New Day Bridges Care Plan (HMO SNP)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$8.00 | $16.00 | P Q:60 /30Days | $14.00 |
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 | P Q:60 /30Days | $14.00 |
Browse Plan Formulary |
Brand New Day Classic Care I Plan (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$8.00 | $16.00 | P Q:60 /30Days | $14.00 |
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 |
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 | P Q:60 /30Days | $14.00 |
Browse Plan Formulary |
Brand New Day Classic Care II Plan (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$10.00 | $20.00 | P Q:60 /30Days | $14.00 |
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 | P Q:60 /30Days | $14.00 |
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 | P Q:60 /30Days | $14.00 |
Browse Plan Formulary |
Brand New Day Embrace Care Plan (HMO SNP)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$8.00 | $16.00 | P Q:60 /30Days | $14.00 |
Browse Plan Formulary |
Brand New Day Embrace Care Plan (HMO SNP)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$8.00 | $16.00 | P Q:60 /30Days | $14.00 |
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 |
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 | P Q:60 /30Days | $14.00 |
Browse Plan Formulary |
Brand New Day Harmony Care Plan (HMO SNP)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$9.00 | $18.00 | P Q:60 /30Days | $14.00 |
Browse Plan Formulary |
Central Health Focus Plan (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | $10.00 | P Q:60 /30Days | $13.85 |
Browse Plan Formulary |
Central Health Focus Plan (HMO SNP)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$5.00 | $10.00 | P Q:60 /30Days | $13.85 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO SNP)
|
$0.00 |
$415* | to be determined | 2* |
Generic |
$0.00 | $0.00 | P Q:60 /30Days | $13.85 |
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 | P Q:60 /30Days | $13.85 |
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 |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$5.00 | $10.00 | P Q:60 /30Days | $13.85 |
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:60 /30Days | $14.60 |
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:60 /30Days | $14.90 |
Browse Plan Formulary |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Generic Drugs |
0% | 0% | P | $8.93 |
Browse Plan Formulary |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Generic Drugs |
0% | 0% | P | $8.93 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$37.00 | $101.00 | P | $24.95 |
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. | 3 |
Preferred Brand |
$37.00 | $101.00 | P | $25.15 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 | to be determined | 3 |
Preferred Brand |
$37.00 | $101.00 | P | $24.95 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 | to be determined | 3 |
Preferred Brand |
$37.00 | $101.00 | P | $25.15 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 | to be determined | 3 |
Preferred Brand |
$37.00 | $101.00 | P | $24.95 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 | to be determined | 3 |
Preferred Brand |
$37.00 | $101.00 | P | $25.15 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$37.00 | $101.00 | P | $24.95 |
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 | 3 |
Preferred Brand |
$37.00 | $101.00 | P | $24.95 |
Browse Plan Formulary |
Imperial Senior Value (HMO SNP) (HMO SNP)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$5.00 | $10.00 | P Q:60 /30Days | $19.80 |
Browse Plan Formulary |
Imperial Traditional (HMO) (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$5.00 | $10.00 | P Q:60 /30Days | $19.80 |
Browse Plan Formulary |
Inter Valley Health Plan Service To Seniors (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$12.00 | $24.00 | P Q:60 /30Days | $9.53 |
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 | $13.75 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Generic |
$15.00 | $30.00 | None | $13.75 |
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 | Yes, but No Gap Coverage for this drug. | 1 |
Generic Drugs |
0% | 0% | P Q:30 /30Days | $9.64 |
Browse Plan Formulary |
L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 1 |
Generic Drugs |
0% | 0% | P Q:30 /30Days | $9.64 |
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% | P Q:60 /30Days | $20.06 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Brand Drugs |
0% | 0% | P Q:60 /30Days | $20.06 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$0.00 |
$415 | to be determined | 2 |
Generic |
$8.00 | $24.00 | P Q:60 /30Days | $20.07 |
Browse Plan Formulary |
PHP (HMO SNP)
|
$0.00 |
$415 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
25% | n/a | P Q:60 /30Days | $13.85 |
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 |
PHP (HMO SNP)
|
$0.00 |
$415 | to be determined | 1 |
Generic |
25% | n/a | P Q:60 /30Days | $13.85 |
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 | $13.61 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$12.50 |
$0 | to be determined | 2 |
Generic |
$15.00 | $30.00 | None | $13.61 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$12.50 |
$0 | to be determined | 2 |
Generic |
$15.00 | $30.00 | None | $13.61 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$15.20 |
$415 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$8.00 | $24.00 | P Q:60 /30Days | $20.07 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$16.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$37.00 | $101.00 | P | $24.95 |
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. | 3 |
Preferred Brand |
$37.00 | $101.00 | P | $25.15 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Assure (HMO)
|
$16.10 |
$415 | No additional gap coverage, only the Donut Hole Discount | 3 |
All Formulary Drugs |
25% | 25% | Q:60 /30Days | $39.49 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Assure (HMO)
|
$16.10 |
$415 | to be determined | 3 |
All Formulary Drugs |
25% | 25% | Q:60 /30Days | $39.49 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Premier (HMO)
|
$18.30 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $39.66 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Premier (HMO)
|
$18.30 |
$0 | to be determined | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $39.66 |
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 | $13.62 |
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 |
Alignment Health Plan CalPlus (HMO)
|
$30.50 |
$415 | to be determined | 2 |
Generic |
$10.00 | $30.00 | None | $13.62 |
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% | P Q:60 /30Days | $15.48 |
Browse Plan Formulary |
Anthem Connect Plus (HMO)
|
$34.70 |
$415 | to be determined | 2 |
All Formulary Drugs |
25% | 25% | P Q:60 /30Days | $15.48 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$34.80 |
$415 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$9.00 | $27.00 | P Q:60 /30Days | $15.44 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$34.80 |
$415 | to be determined | 2 |
Generic |
$9.00 | $27.00 | P Q:60 /30Days | $15.44 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$34.80 |
$415 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$2.00 | $6.00 | P Q:60 /30Days | $15.56 |
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 |
Anthem MediBlue Extra (HMO)
|
$34.80 |
$415 | to be determined | 2 |
Generic |
$2.00 | $6.00 | P Q:60 /30Days | $15.56 |
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% | P Q:60 /30Days | $14.00 |
Browse Plan Formulary |
Brand New Day Bridges Choice Medi-Medi Plan (HMO SNP)
|
$34.80 |
$415 | to be determined | 2 |
Generic |
25% | 25% | P Q:60 /30Days | $14.00 |
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% | P Q:60 /30Days | $14.00 |
Browse Plan Formulary |
Brand New Day Classic Choice Medi-Medi Plan (HMO)
|
$34.80 |
$415 | to be determined | 2 |
Generic |
25% | 25% | P Q:60 /30Days | $14.00 |
Browse Plan Formulary |
Brand New Day Dual Access Plan (HMO SNP)
|
$34.80 |
$415* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
0% | 0% | P Q:60 /30Days | $14.00 |
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 |
Brand New Day Dual Access Plan (HMO SNP)
|
$34.80 |
$415* | to be determined | 2* |
Generic |
0% | 0% | P Q:60 /30Days | $14.00 |
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% | P Q:60 /30Days | $14.00 |
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% | P Q:60 /30Days | $14.00 |
Browse Plan Formulary |
Brand New Day Embrace Choice Medi-Medi Plan (HMO SNP)
|
$34.80 |
$415 | to be determined | 2 |
Generic |
25% | 25% | P Q:60 /30Days | $14.00 |
Browse Plan Formulary |
Brand New Day Embrace Choice Medi-Medi Plan (HMO SNP)
|
$34.80 |
$415 | to be determined | 2 |
Generic |
25% | 25% | P Q:60 /30Days | $14.00 |
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% | P Q:60 /30Days | $14.00 |
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 |
Brand New Day Harmony Choice Plan (HMO SNP)
|
$34.80 |
$415 | to be determined | 2 |
Generic |
25% | 25% | P Q:60 /30Days | $14.00 |
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% | P Q:60 /30Days | $14.00 |
Browse Plan Formulary |
Brand New Day Select Care Plan (HMO SNP)
|
$34.80 |
$415 | to be determined | 2 |
Generic |
25% | 25% | P Q:60 /30Days | $14.00 |
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 | P Q:60 /30Days | $13.85 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$34.80 |
$415* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$0.00 | $0.00 | P Q:60 /30Days | $13.85 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$34.80 |
$415* | to be determined | 2* |
Generic |
$0.00 | $0.00 | P Q:60 /30Days | $13.85 |
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 |
Health Net Seniority Plus Amber I (HMO SNP)
|
$34.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | P | $9.03 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$34.80 |
$320 | to be determined | 3 |
Preferred Brand |
$47.00 | $141.00 | P | $9.03 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | P | $9.02 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | P | $9.03 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | P | $9.03 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 | to be determined | 3 |
Preferred Brand |
$47.00 | $141.00 | P | $9.02 |
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 | to be determined | 3 |
Preferred Brand |
$47.00 | $141.00 | P | $9.03 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$34.80 |
$300 | to be determined | 3 |
Preferred Brand |
$47.00 | $141.00 | P | $9.03 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | P | $9.02 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | P | $9.03 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | P | $9.03 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 | to be determined | 3 |
Preferred Brand |
$47.00 | $141.00 | P | $9.02 |
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 | 3 |
Preferred Brand |
$47.00 | $141.00 | P | $9.03 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 | to be determined | 3 |
Preferred Brand |
$47.00 | $141.00 | P | $9.03 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$34.80 |
$285 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | P | $9.02 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$34.80 |
$285 | to be determined | 3 |
Preferred Brand |
$47.00 | $141.00 | P | $9.02 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier II (HMO)
|
$34.80 |
$280 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | P | $9.02 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier II (HMO)
|
$34.80 |
$280 | to be determined | 3 |
Preferred Brand |
$47.00 | $141.00 | P | $9.02 |
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 |
Imperial Traditional Plus (HMO) (HMO)
|
$34.80 |
$415 | to be determined | 2 |
Generic |
25% | 25% | P Q:60 /30Days | $19.80 |
Browse Plan Formulary |
Inter Valley Health Plan Value Preferred Choice (HMO)
|
$34.80 |
$415 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
25% | 25% | P Q:60 /30Days | $9.53 |
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 | $13.61 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$40.90 |
$0 | to be determined | 3 |
Preferred Brand |
$47.00 | $136.00 | P Q:60 /30Days | $45.48 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$73.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $136.00 | P Q:60 /30Days | $45.48 |
Browse Plan Formulary |