AMNESTEEM 20 MG CAPSULE (30 EA ) (NDC: 00378661293)
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 |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $201.58 |
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 | $201.58 |
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 | $201.58 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $201.58 |
Browse Plan Formulary |
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 | $286.80 |
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 |
3 |
Preferred Brand |
$30.00 | $75.00 | None | $286.80 |
Browse Plan Formulary |
Alignment Health Plan My Choice (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$30.00 | $75.00 | None | $286.80 |
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 | $286.80 |
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 | $286.80 |
Browse Plan Formulary |
Alignment Health Plan Platinum (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$30.00 | $75.00 | None | $286.80 |
Browse Plan Formulary |
Alignment Health Plan smartHMO (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Preferred Brand |
$30.00 | $75.00 | None | $286.80 |
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 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | $75.00 | None | $286.80 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | None | $394.97 |
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 | None | $394.97 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | None | $394.97 |
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 | P | $281.99 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$0.00 | $0.00 | P | $281.99 |
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 Freedom Plan (HMO SNP)
|
$0.00 |
$415 |
to be determined |
4 |
Non-Preferred Drug |
50% | 50% | P | $281.99 |
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 | $448.08 |
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 | $448.08 |
Browse Plan Formulary |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Generic Drugs |
0% | 0% | None | $237.62 |
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% | None | $237.62 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$90.00 | $260.00 | None | $440.52 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $260.00 | None | $376.20 |
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 | None | $440.52 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$90.00 | $260.00 | None | $376.20 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$90.00 | $260.00 | None | $440.52 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$90.00 | $260.00 | None | $376.20 |
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 | None | $440.52 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$90.00 | $260.00 | None | $440.52 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:60 /30Days | $243.54 |
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:60 /30Days | $243.54 |
Browse Plan Formulary |
Imperial Senior Value (HMO SNP) (HMO SNP)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$5.00 | $10.00 | None | $786.11 |
Browse Plan Formulary |
Imperial Traditional (HMO) (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$5.00 | $10.00 | None | $786.11 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Generic |
$15.00 | $30.00 | None | $238.28 |
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 |
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 | $238.28 |
Browse Plan Formulary |
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% | None | $245.14 |
Browse Plan Formulary |
L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Generic Drugs |
0% | 0% | None | $245.14 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
to be determined |
1 |
Generic Drugs |
0% | 0% | P | $391.42 |
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% | P | $391.42 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$0.00 |
$415 |
to be determined |
4 |
Non-Preferred Drug |
33% | 33% | P | $391.42 |
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 |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $235.11 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $235.11 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $235.11 |
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 | $235.11 |
Browse Plan Formulary |
SCAN Classic II (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $235.11 |
Browse Plan Formulary |
SCAN Connections (HMO SNP)
|
$0.00 |
$415 |
to be determined |
4 |
Non-Preferred Drug |
25% | 25% | None | $235.11 |
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 |
4 |
Non-Preferred Drug |
25% | 25% | None | $235.11 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $235.11 |
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 | $235.11 |
Browse Plan Formulary |
SCAN Prime (HMO)
|
$0.00 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $235.11 |
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 | $238.28 |
Browse Plan Formulary |
Easy Choice Rx (HMO)
|
$12.00 |
$415 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $0.00 | P | $281.99 |
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 | P | $281.99 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$12.50 |
$0 |
to be determined |
2 |
Generic |
$15.00 | $30.00 | None | $238.28 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$12.50 |
$0 |
to be determined |
2 |
Generic |
$15.00 | $30.00 | None | $238.28 |
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% | P | $391.42 |
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 | None | $376.20 |
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 | None | $440.52 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Easy Choice Freedom Plan (HMO SNP)
|
$19.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | P | $281.99 |
Browse Plan Formulary |
SCAN Prime (HMO)
|
$25.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $235.11 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$26.30 |
$415 |
to be determined |
2 |
Generic |
$20.00 | $0.00 | P | $281.99 |
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 | P | $281.99 |
Browse Plan Formulary |
Alignment Health Plan CalPlus (HMO)
|
$30.50 |
$415 |
to be determined |
3 |
Preferred Brand |
25% | 25% | None | $344.21 |
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 | $344.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SCAN Classic II (HMO)
|
$32.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $235.11 |
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:60 /30Days | $243.54 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$33.30 |
$415 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $243.54 |
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 | $235.11 |
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 | None | $246.85 |
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 | None | $246.85 |
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 II (HMO SNP)
|
$34.80 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $243.78 |
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 | None | $243.78 |
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 | None | $243.78 |
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 | None | $246.85 |
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 | None | $243.78 |
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 | None | $246.85 |
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 Sapphire (HMO)
|
$34.80 |
$340 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $246.85 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $243.78 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $246.85 |
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 | None | $243.78 |
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 | None | $243.78 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$34.80 |
$340 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $243.78 |
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 (HMO)
|
$34.80 |
$285 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $246.85 |
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 | None | $246.85 |
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 | None | $246.85 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier II (HMO)
|
$34.80 |
$280 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $246.85 |
Browse Plan Formulary |
Imperial Traditional Plus (HMO) (HMO)
|
$34.80 |
$415 |
to be determined |
2 |
Generic |
25% | 25% | None | $786.11 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
|
$34.80 |
$415 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | 25% | None | $235.11 |
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 Plus (HMO)
|
$34.80 |
$415 |
to be determined |
4 |
Non-Preferred Drug |
25% | 25% | None | $235.11 |
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 | $235.11 |
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 | $238.28 |
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 | $235.11 |
Browse Plan Formulary |
VillageHealth (HMO-POS SNP)
|
$34.80 |
$415 |
to be determined |
4 |
Non-Preferred Drug |
25% | 25% | None | $235.11 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$40.90 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $201.58 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
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 | $201.58 |
Browse Plan Formulary |