DALIRESP 500 MCG TABLET (30 EA ) (NDC: 00310009530)
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 | P Q:30 /30Days | $385.51 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Focus (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days | $385.51 |
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:30 /30Days | $385.51 |
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:30 /30Days | $385.51 |
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 | P Q:30 /30Days | $385.51 |
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 |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days | $385.51 |
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 | $369.25 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $369.25 |
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 | $369.25 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $369.25 |
Browse Plan Formulary |
Alignment Health Plan Heart & Diabetes (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$75.00 | $187.50 | P Q:30 /30Days | $362.23 |
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 | 4 |
Non-Preferred Brand |
$75.00 | $187.50 | P Q:30 /30Days | $362.23 |
Browse Plan Formulary |
Alignment Health Plan My Choice (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$75.00 | $187.50 | P Q:30 /30Days | $361.86 |
Browse Plan Formulary |
Alignment Health Plan My Choice (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Brand |
$75.00 | $187.50 | P Q:30 /30Days | $361.86 |
Browse Plan Formulary |
Alignment Health Plan Platinum (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$75.00 | $187.50 | P Q:30 /30Days | $362.23 |
Browse Plan Formulary |
Alignment Health Plan Platinum (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Brand |
$75.00 | $187.50 | P Q:30 /30Days | $362.23 |
Browse Plan Formulary |
Alignment Health Plan smartHMO (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$75.00 | $187.50 | P Q:30 /30Days | $362.39 |
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 | 4 |
Non-Preferred Brand |
$75.00 | $187.50 | P Q:30 /30Days | $362.39 |
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:30 /30Days | $352.21 |
Browse Plan Formulary |
Anthem Blue Cross Cal MediConnect (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Brand Drugs |
0% | 0% | P Q:30 /30Days | $352.21 |
Browse Plan Formulary |
Anthem Breathe (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | P Q:30 /30Days | $352.36 |
Browse Plan Formulary |
Anthem Breathe (HMO SNP)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | P Q:30 /30Days | $352.36 |
Browse Plan Formulary |
Anthem Care On Site (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | P Q:30 /30Days | $352.36 |
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 | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | P Q:30 /30Days | $352.36 |
Browse Plan Formulary |
Anthem Connect (HMO SNP)
|
$0.00 |
$415 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
25% | 25% | P Q:30 /30Days | $352.21 |
Browse Plan Formulary |
Anthem Connect (HMO SNP)
|
$0.00 |
$415 | to be determined | 4 |
Non-Preferred Drug |
25% | 25% | P Q:30 /30Days | $352.21 |
Browse Plan Formulary |
Anthem Diabetes (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | P Q:30 /30Days | $352.36 |
Browse Plan Formulary |
Anthem Diabetes (HMO SNP)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | P Q:30 /30Days | $352.36 |
Browse Plan Formulary |
Anthem ESRD (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | P Q:30 /30Days | $352.36 |
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 | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | P Q:30 /30Days | $352.36 |
Browse Plan Formulary |
Anthem Heart (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | P Q:30 /30Days | $352.36 |
Browse Plan Formulary |
Anthem Heart (HMO SNP)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | P Q:30 /30Days | $352.36 |
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 | P Q:30 /30Days | $352.43 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:30 /30Days | $352.43 |
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 | P Q:30 /30Days | $352.28 |
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 | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:30 /30Days | $352.28 |
Browse Plan Formulary |
Anthem StartSmart Plus (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:30 /30Days | $352.59 |
Browse Plan Formulary |
Anthem StartSmart Plus (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:30 /30Days | $352.59 |
Browse Plan Formulary |
Anthem Value Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | P Q:30 /30Days | $352.36 |
Browse Plan Formulary |
Anthem Value Plus (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | P Q:30 /30Days | $352.36 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $237.50 | P Q:1 /1Days | $353.34 |
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 | 4 |
Non-Preferred Drug |
$95.00 | $237.50 | P Q:1 /1Days | $353.34 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$95.00 | $237.50 | P Q:1 /1Days | $353.34 |
Browse Plan Formulary |
Brand New Day Bridges Care Plan (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days | $354.65 |
Browse Plan Formulary |
Brand New Day Bridges Care Plan (HMO SNP)
|
$0.00 |
$0 | to be determined | 3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days | $354.65 |
Browse Plan Formulary |
Brand New Day Classic Care I Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days | $354.65 |
Browse Plan Formulary |
Brand New Day Classic Care I Plan (HMO)
|
$0.00 |
$0 | to be determined | 3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days | $354.65 |
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 |
Brand New Day Classic Care II Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days | $354.65 |
Browse Plan Formulary |
Brand New Day Classic Care II Plan (HMO)
|
$0.00 |
$0 | to be determined | 3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days | $354.65 |
Browse Plan Formulary |
Brand New Day Embrace Care Plan (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days | $354.65 |
Browse Plan Formulary |
Brand New Day Embrace Care Plan (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days | $354.65 |
Browse Plan Formulary |
Brand New Day Embrace Care Plan (HMO SNP)
|
$0.00 |
$0 | to be determined | 3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days | $354.65 |
Browse Plan Formulary |
Brand New Day Embrace Care Plan (HMO SNP)
|
$0.00 |
$0 | to be determined | 3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days | $354.65 |
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 |
Brand New Day Harmony Care Plan (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days | $354.65 |
Browse Plan Formulary |
Brand New Day Harmony Care Plan (HMO SNP)
|
$0.00 |
$0 | to be determined | 3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days | $354.65 |
Browse Plan Formulary |
Central Health Focus Plan (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $70.00 | Q:30 /30Days | $351.26 |
Browse Plan Formulary |
Central Health Focus Plan (HMO SNP)
|
$0.00 |
$0 | to be determined | 3 |
Preferred Brand |
$35.00 | $70.00 | Q:30 /30Days | $351.26 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO SNP)
|
$0.00 |
$415 | to be determined | 3 |
Preferred Brand |
25% | 25% | Q:30 /30Days | $351.26 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $70.00 | Q:30 /30Days | $351.26 |
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 |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 | to be determined | 3 |
Preferred Brand |
$35.00 | $70.00 | Q:30 /30Days | $351.26 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$99.00 | $198.00 | None | $365.47 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$99.00 | $198.00 | None | $365.47 |
Browse Plan Formulary |
Easy Choice Freedom Plan (HMO SNP)
|
$0.00 |
$415 | to be determined | 4 |
Non-Preferred Drug |
50% | 50% | None | $365.47 |
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 | $368.55 |
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 | $369.23 |
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 Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Brand Drugs |
0% | 0% | Q:1 /1Days | $357.35 |
Browse Plan Formulary |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Brand Drugs |
0% | 0% | Q:1 /1Days | $357.35 |
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 | Q:1 /1Days | $368.14 |
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 | Q:1 /1Days | $367.76 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$90.00 | $260.00 | Q:1 /1Days | $368.14 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$90.00 | $260.00 | Q:1 /1Days | $367.76 |
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 Healthy Heart (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$90.00 | $260.00 | Q:1 /1Days | $368.14 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$90.00 | $260.00 | Q:1 /1Days | $367.76 |
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 | Q:1 /1Days | $368.12 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$90.00 | $260.00 | Q:1 /1Days | $368.12 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $70.00 | Q:30 /30Days | $379.65 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 | to be determined | 3 |
Preferred Brand |
$35.00 | $70.00 | Q:30 /30Days | $379.65 |
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 |
Imperial Senior Value (HMO SNP) (HMO SNP)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$90.00 | $180.00 | P Q:30 /30Days | $371.74 |
Browse Plan Formulary |
Imperial Traditional (HMO) (HMO)
|
$0.00 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$90.00 | $180.00 | P Q:30 /30Days | $371.74 |
Browse Plan Formulary |
Inter Valley Health Plan Service To Seniors (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $117.50 | Q:30 /30Days | $360.54 |
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 | None | $400.09 |
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 | None | $400.09 |
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% | None | $360.22 |
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 |
L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Brand Drugs |
0% | 0% | None | $360.22 |
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 | $357.32 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 | to be determined | 2 |
Brand Drugs |
0% | 0% | None | $357.32 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$0.00 |
$415 | to be determined | 4 |
Non-Preferred Drug |
33% | 33% | None | $356.93 |
Browse Plan Formulary |
PHP (HMO SNP)
|
$0.00 |
$415 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
25% | n/a | Q:30 /30Days | $351.27 |
Browse Plan Formulary |
PHP (HMO SNP)
|
$0.00 |
$415 | to be determined | 2 |
Preferred Brand |
25% | n/a | Q:30 /30Days | $351.27 |
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 Balance (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$30.00 | $80.00 | None | $351.78 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 | to be determined | 3 |
Preferred Brand |
$30.00 | $80.00 | None | $351.78 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $116.00 | None | $351.66 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 | to be determined | 3 |
Preferred Brand |
$42.00 | $116.00 | None | $351.66 |
Browse Plan Formulary |
SCAN Classic II (HMO)
|
$0.00 |
$0 | to be determined | 3 |
Preferred Brand |
$42.00 | $116.00 | None | $351.66 |
Browse Plan Formulary |
SCAN Connections (HMO SNP)
|
$0.00 |
$415 | to be determined | 3 |
Preferred Brand |
25% | 25% | None | $352.13 |
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)
|
$0.00 |
$415 | to be determined | 3 |
Preferred Brand |
25% | 25% | None | $351.66 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $352.17 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 | to be determined | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $352.17 |
Browse Plan Formulary |
SCAN Prime (HMO)
|
$0.00 |
$0 | to be determined | 3 |
Preferred Brand |
$42.00 | $116.00 | None | $351.66 |
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 | None | $395.56 |
Browse Plan Formulary |
Easy Choice Rx (HMO)
|
$12.00 |
$415 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $365.47 |
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 | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $365.47 |
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 | None | $395.56 |
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 | None | $395.56 |
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 | $356.93 |
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 | Q:1 /1Days | $368.14 |
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 | Q:1 /1Days | $367.76 |
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 |
UnitedHealthcare MedicareComplete Assure (HMO)
|
$16.10 |
$415 | No additional gap coverage, only the Donut Hole Discount | 4 |
All Formulary Drugs |
25% | 25% | P Q:30 /30Days | $385.93 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Assure (HMO)
|
$16.10 |
$415 | to be determined | 4 |
All Formulary Drugs |
25% | 25% | P Q:30 /30Days | $385.93 |
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:30 /30Days | $385.51 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Premier (HMO)
|
$18.30 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:30 /30Days | $385.51 |
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% | None | $365.47 |
Browse Plan Formulary |
SCAN Prime (HMO)
|
$25.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $116.00 | None | $351.66 |
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 |
Easy Choice Plus Plan (HMO)
|
$26.30 |
$415 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$99.00 | $198.00 | None | $365.47 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$26.30 |
$415 | to be determined | 4 |
Non-Preferred Drug |
$99.00 | $198.00 | None | $365.47 |
Browse Plan Formulary |
Alignment Health Plan CalPlus (HMO)
|
$30.50 |
$415 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
25% | 25% | P Q:30 /30Days | $361.62 |
Browse Plan Formulary |
Alignment Health Plan CalPlus (HMO)
|
$30.50 |
$415 | to be determined | 4 |
Non-Preferred Brand |
25% | 25% | P Q:30 /30Days | $361.62 |
Browse Plan Formulary |
SCAN Classic II (HMO)
|
$32.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $116.00 | None | $351.66 |
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 | Q:30 /30Days | $379.69 |
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 | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $379.69 |
Browse Plan Formulary |
SCAN Connections (HMO SNP)
|
$33.40 |
$415 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
25% | 25% | None | $352.13 |
Browse Plan Formulary |
Anthem Connect Plus (HMO)
|
$34.70 |
$415 | No additional gap coverage, only the Donut Hole Discount | 4 |
All Formulary Drugs |
25% | 25% | P Q:30 /30Days | $352.61 |
Browse Plan Formulary |
Anthem Connect Plus (HMO)
|
$34.70 |
$415 | to be determined | 4 |
All Formulary Drugs |
25% | 25% | P Q:30 /30Days | $352.61 |
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 | P Q:30 /30Days | $352.43 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$34.80 |
$415 | to be determined | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:30 /30Days | $352.43 |
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 MediBlue Extra (HMO)
|
$34.80 |
$415 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:30 /30Days | $352.28 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$34.80 |
$415 | to be determined | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | P Q:30 /30Days | $352.28 |
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 | 3 |
Preferred Brand |
25% | 25% | Q:30 /30Days | $354.65 |
Browse Plan Formulary |
Brand New Day Bridges Choice Medi-Medi Plan (HMO SNP)
|
$34.80 |
$415 | to be determined | 3 |
Preferred Brand |
25% | 25% | Q:30 /30Days | $354.65 |
Browse Plan Formulary |
Brand New Day Classic Choice Medi-Medi Plan (HMO)
|
$34.80 |
$415 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | 25% | Q:30 /30Days | $354.65 |
Browse Plan Formulary |
Brand New Day Classic Choice Medi-Medi Plan (HMO)
|
$34.80 |
$415 | to be determined | 3 |
Preferred Brand |
25% | 25% | Q:30 /30Days | $354.65 |
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 |
Brand New Day Dual Access Plan (HMO SNP)
|
$34.80 |
$415 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | 25% | Q:30 /30Days | $354.65 |
Browse Plan Formulary |
Brand New Day Dual Access Plan (HMO SNP)
|
$34.80 |
$415 | to be determined | 3 |
Preferred Brand |
25% | 25% | Q:30 /30Days | $354.65 |
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 | 3 |
Preferred Brand |
25% | 25% | Q:30 /30Days | $354.65 |
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 | 3 |
Preferred Brand |
25% | 25% | Q:30 /30Days | $354.65 |
Browse Plan Formulary |
Brand New Day Embrace Choice Medi-Medi Plan (HMO SNP)
|
$34.80 |
$415 | to be determined | 3 |
Preferred Brand |
25% | 25% | Q:30 /30Days | $354.65 |
Browse Plan Formulary |
Brand New Day Embrace Choice Medi-Medi Plan (HMO SNP)
|
$34.80 |
$415 | to be determined | 3 |
Preferred Brand |
25% | 25% | Q:30 /30Days | $354.65 |
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 |
Brand New Day Harmony Choice Plan (HMO SNP)
|
$34.80 |
$415 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | 25% | Q:30 /30Days | $354.65 |
Browse Plan Formulary |
Brand New Day Harmony Choice Plan (HMO SNP)
|
$34.80 |
$415 | to be determined | 3 |
Preferred Brand |
25% | 25% | Q:30 /30Days | $354.65 |
Browse Plan Formulary |
Brand New Day Select Care Plan (HMO SNP)
|
$34.80 |
$415 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | 25% | Q:30 /30Days | $354.65 |
Browse Plan Formulary |
Brand New Day Select Care Plan (HMO SNP)
|
$34.80 |
$415 | to be determined | 3 |
Preferred Brand |
25% | 25% | Q:30 /30Days | $354.65 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO SNP)
|
$34.80 |
$415 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
25% | 25% | Q:30 /30Days | $351.26 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$34.80 |
$415 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
25% | 25% | Q:30 /30Days | $351.26 |
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 |
Central Health Premier Plan (HMO)
|
$34.80 |
$415 | to be determined | 3 |
Preferred Brand |
25% | 25% | Q:30 /30Days | $351.26 |
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 | Q:1 /1Days | $365.50 |
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 | Q:1 /1Days | $365.50 |
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 | Q:1 /1Days | $365.52 |
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 | Q:1 /1Days | $365.47 |
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 | Q:1 /1Days | $365.47 |
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 | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:1 /1Days | $365.52 |
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 | Q:1 /1Days | $365.47 |
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 | Q:1 /1Days | $365.47 |
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 | Q:1 /1Days | $365.47 |
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 | Q:1 /1Days | $365.47 |
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 | Q:1 /1Days | $365.47 |
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 | Q:1 /1Days | $365.47 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:1 /1Days | $365.47 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:1 /1Days | $365.47 |
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 | Q:1 /1Days | $365.51 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$34.80 |
$285 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:1 /1Days | $365.51 |
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 | Q:1 /1Days | $365.51 |
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 Seniority Plus Sapphire Premier II (HMO)
|
$34.80 |
$280 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:1 /1Days | $365.51 |
Browse Plan Formulary |
Imperial Traditional Plus (HMO) (HMO)
|
$34.80 |
$415 | to be determined | 4 |
Non-Preferred Drug |
25% | 25% | P Q:30 /30Days | $371.74 |
Browse Plan Formulary |
Inter Valley Health Plan Value Preferred Choice (HMO)
|
$34.80 |
$415 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | 25% | Q:30 /30Days | $360.30 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
|
$34.80 |
$415 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
25% | 25% | None | $351.66 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$34.80 |
$415 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | 25% | None | $352.18 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$34.80 |
$415 | to be determined | 3 |
Preferred Brand |
25% | 25% | None | $352.18 |
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)
|
$34.80 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$100.00 | $200.00 | None | $395.56 |
Browse Plan Formulary |
VillageHealth (HMO-POS SNP)
|
$34.80 |
$415 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | 25% | None | $351.78 |
Browse Plan Formulary |
VillageHealth (HMO-POS SNP)
|
$34.80 |
$415 | to be determined | 3 |
Preferred Brand |
25% | 25% | None | $351.78 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$40.90 |
$0 | to be determined | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $369.25 |
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 | None | $369.25 |
Browse Plan Formulary |