CHLORPROMAZINE 200 MG TABLET (100.000 EA ) (NDC: 00832030400)
2020 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 Medicare Advantage SecureHorizons Focus (HMO)
|
$0.00 |
$0 | No | 4 |
Tier 4 |
$100.00 | $290.00 | None | $501.60 |
Browse Plan Formulary |
AARP Medicare Advantage SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 | No | 4 |
Tier 4 |
$100.00 | $290.00 | None | $501.60 |
Browse Plan Formulary |
AARP Medicare Advantage SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 | No | 4 |
Tier 4 |
$100.00 | $290.00 | None | $501.60 |
Browse Plan Formulary |
Aetna Medicare Plus Plan (HMO)
|
$0.00 |
$0 | No | 4 |
Tier 4 |
$99.00 | $297.00 | None | $248.40 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 | No | 4 |
Tier 4 |
$100.00 | $300.00 | None | $248.40 |
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 Select Plan (HMO)
|
$0.00 |
$0 | No | 4 |
Tier 4 |
$100.00 | $300.00 | None | $248.40 |
Browse Plan Formulary |
Alignment Health Plan Heart & Diabetes (HMO C-SNP)
|
$0.00 |
$0 | No | 5 |
Tier 5 |
33% | n/a | P | $745.80 |
Browse Plan Formulary |
Alignment Health Plan My Choice (HMO)
|
$0.00 |
$0 | No | 5 |
Tier 5 |
33% | n/a | P | $747.00 |
Browse Plan Formulary |
Alignment Health Plan Platinum (HMO)
|
$0.00 |
$0 | No | 5 |
Tier 5 |
33% | n/a | P | $745.80 |
Browse Plan Formulary |
Alignment Health Plan smartHMO (HMO)
|
$0.00 |
$0 | No | 5 |
Tier 5 |
33% | n/a | P | $775.80 |
Browse Plan Formulary |
Anthem Blue Cross Cal MediConnect (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
0% | 0% | None | $472.20 |
Browse Plan Formulary |
|
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Anthem MediBlue Breathe (HMO C-SNP)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
$7.50 | $15.00 | None | $718.80 |
Browse Plan Formulary |
Anthem MediBlue Care On Site (HMO I-SNP)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
$9.50 | $19.00 | None | $718.80 |
Browse Plan Formulary |
Anthem MediBlue Connect (HMO D-SNP)
|
$0.00 |
$435* | No | 2* |
Tier 2 |
$0.00 | $0.00 | None | $718.80 |
Browse Plan Formulary |
Anthem MediBlue Diabetes (HMO C-SNP)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
$7.50 | $15.00 | None | $718.80 |
Browse Plan Formulary |
Anthem MediBlue ESRD (HMO C-SNP)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
$7.50 | $15.00 | None | $718.80 |
Browse Plan Formulary |
Anthem MediBlue Heart (HMO C-SNP)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
$7.50 | $15.00 | None | $718.80 |
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 |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 | No | 4 |
Tier 4 |
$95.00 | $285.00 | None | $568.20 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 | No | 4 |
Tier 4 |
$95.00 | $190.00 | None | $584.40 |
Browse Plan Formulary |
Anthem MediBlue StartSmart Plus (HMO)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
$14.50 | $29.00 | None | $718.80 |
Browse Plan Formulary |
Anthem MediBlue Value Plus (HMO)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
$9.50 | $19.00 | None | $718.80 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 | No | 4 |
Tier 4 |
$95.00 | $237.50 | None | $1,027.80 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 | No | 4 |
Tier 4 |
$95.00 | $237.50 | None | $1,027.80 |
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 |
Blue Shield Inspire (HMO)
|
$0.00 |
$0 | No | 4 |
Tier 4 |
$90.00 | $225.00 | None | $1,027.80 |
Browse Plan Formulary |
Blue Shield Promise AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
$3.00 | $7.50 | None | $1,027.80 |
Browse Plan Formulary |
Blue Shield Promise Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
0% | 0% | None | $1,027.80 |
Browse Plan Formulary |
Blue Shield Vital (HMO)
|
$0.00 |
$0 | No | 4 |
Tier 4 |
$95.00 | $237.50 | None | $1,027.80 |
Browse Plan Formulary |
Central Health Focus Plan (HMO C-SNP)
|
$0.00 |
$0 | No | 4 |
Tier 4 |
$75.00 | $150.00 | None | $449.40 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 | No | 4 |
Tier 4 |
$75.00 | $150.00 | None | $449.40 |
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 |
Connected Care (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Tier 4 |
$95.00 | $0.00 | None | $449.40 |
Browse Plan Formulary |
Connected Care Select (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Tier 4 |
$95.00 | $0.00 | None | $449.40 |
Browse Plan Formulary |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No | 1 |
Tier 1 |
0% | 0% | None | $390.00 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 | No | 4 |
Tier 4 |
$90.00 | $260.00 | None | $518.40 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 | No | 4 |
Tier 4 |
$90.00 | $260.00 | None | $519.60 |
Browse Plan Formulary |
Health Net Jade (HMO C-SNP)
|
$0.00 |
$0 | No | 4 |
Tier 4 |
$90.00 | $260.00 | None | $518.40 |
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)
|
$0.00 |
$370 | No | 4 |
Tier 4 |
$100.00 | $300.00 | None | $403.20 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 | No | 4 |
Tier 4 |
$100.00 | $200.00 | None | $592.80 |
Browse Plan Formulary |
Imperial Senior Value (HMO C-SNP)
|
$0.00 |
$0 | No | 4 |
Tier 4 |
$90.00 | $180.00 | P | $823.80 |
Browse Plan Formulary |
Imperial Traditional (HMO) (HMO)
|
$0.00 |
$0 | No | 4 |
Tier 4 |
$90.00 | $180.00 | P | $823.80 |
Browse Plan Formulary |
Inter Valley Health Plan Service To Seniors (HMO)
|
$0.00 |
$0 | No | 4 |
Tier 4 |
25% | 25% | None | $511.20 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
$15.00 | $30.00 | None | $534.00 |
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 |
L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No | 1 |
Tier 1 |
0% | 0% | None | $516.00 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No | 1 |
Tier 1 |
0% | 0% | None | $566.40 |
Browse Plan Formulary |
PHP (HMO C-SNP)
|
$0.00 |
$435 | No | 1 |
Tier 1 |
25% | n/a | None | $449.40 |
Browse Plan Formulary |
SCAN Balance (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Tier 4 |
$95.00 | $265.00 | None | $681.60 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 | No | 4 |
Tier 4 |
$95.00 | $265.00 | None | $675.60 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO I-SNP)
|
$0.00 |
$0 | No | 4 |
Tier 4 |
$95.00 | $285.00 | None | $676.20 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
WellCare Best (HMO)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
$0.00 | $0.00 | None | $623.40 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
$10.00 | $0.00 | None | $625.80 |
Browse Plan Formulary |
WellCare Plus (HMO)
|
$0.00 |
$435 | No | 4 |
Tier 4 |
50% | 50% | None | $630.00 |
Browse Plan Formulary |
WellCare Freedom (HMO D-SNP)
|
$1.10 |
$435 | No | 4 |
Tier 4 |
50% | 50% | None | $630.00 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$14.40 |
$435 | No | 4 |
Tier 4 |
$95.00 | $285.00 | None | $553.80 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Assure (HMO)
|
$14.90 |
$435 | No | 4 |
Tier 4 |
25% | 25% | None | $503.40 |
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 B Only South (HMO)
|
$15.40 |
$0 | No | 2 |
Tier 2 |
$15.00 | $30.00 | None | $552.00 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$16.00 |
$0 | No | 4 |
Tier 4 |
$90.00 | $260.00 | None | $518.40 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$16.00 |
$0 | No | 4 |
Tier 4 |
$90.00 | $260.00 | None | $519.60 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$16.80 |
$435 | No | 4 |
Tier 4 |
$100.00 | $290.00 | None | $592.80 |
Browse Plan Formulary |
AARP Medicare Advantage SecureHorizons Premier (HMO)
|
$18.70 |
$0 | No | 4 |
Tier 4 |
$100.00 | $290.00 | None | $501.60 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$20.20 |
$435 | No | 2 |
Tier 2 |
25% | 25% | None | $718.80 |
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 |
SCAN Prime (HMO)
|
$25.00 |
$0 | No | 4 |
Tier 4 |
$95.00 | $265.00 | None | $675.60 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$25.30 |
$435 | No | 4 |
Tier 4 |
$95.00 | $285.00 | None | $568.20 |
Browse Plan Formulary |
Alignment Health Plan CalPlus (HMO)
|
$27.30 |
$435 | No | 5 |
Tier 5 |
25% | n/a | P | $733.20 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP)
|
$31.10 |
$435 | No | 2 |
Tier 2 |
15% | 15% | None | $552.00 |
Browse Plan Formulary |
AARP Medicare Advantage SecureHorizons Focus (HMO)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$100.00 | $290.00 | None | $501.60 |
Browse Plan Formulary |
AARP Medicare Advantage SecureHorizons Plan 1 (HMO)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$100.00 | $290.00 | None | $501.60 |
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 Medicare Advantage SecureHorizons Plan 2 (HMO)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$100.00 | $290.00 | None | $501.60 |
Browse Plan Formulary |
AARP Medicare Advantage SecureHorizons Premier (HMO)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$100.00 | $290.00 | None | $501.60 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$100.00 | $300.00 | None | $241.80 |
Browse Plan Formulary |
Aetna Medicare Plus Plan (HMO)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$99.00 | $297.00 | None | $248.40 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$100.00 | $300.00 | None | $248.40 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$100.00 | $300.00 | None | $248.40 |
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)
|
$32.00 |
$435 | No | 5 |
Tier 5 |
25% | n/a | P | $733.20 |
Browse Plan Formulary |
Alignment Health Plan Heart & Diabetes (HMO C-SNP)
|
$32.00 |
$0 | No | 5 |
Tier 5 |
33% | n/a | P | $745.80 |
Browse Plan Formulary |
Alignment Health Plan My Choice (HMO)
|
$32.00 |
$0 | No | 5 |
Tier 5 |
33% | n/a | P | $747.00 |
Browse Plan Formulary |
Alignment Health Plan Platinum (HMO)
|
$32.00 |
$0 | No | 5 |
Tier 5 |
33% | n/a | P | $745.80 |
Browse Plan Formulary |
Alignment Health Plan smartHMO (HMO)
|
$32.00 |
$0 | No | 5 |
Tier 5 |
33% | n/a | P | $775.80 |
Browse Plan Formulary |
Anthem Blue Cross Cal MediConnect (Medicare-Medicaid Plan)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
0% | 0% | None | $472.20 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Anthem MediBlue Breathe (HMO C-SNP)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
$7.50 | $15.00 | None | $718.80 |
Browse Plan Formulary |
Anthem MediBlue Care On Site (HMO I-SNP)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
$9.50 | $19.00 | None | $718.80 |
Browse Plan Formulary |
Anthem MediBlue Connect (HMO D-SNP)
|
$32.00 |
$435* | No | 2* |
Tier 2 |
$0.00 | $0.00 | None | $718.80 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$32.00 |
$435 | No | 2 |
Tier 2 |
25% | 25% | None | $718.80 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$32.00 |
$435 | No | 4 |
Tier 4 |
$95.00 | $285.00 | None | $568.20 |
Browse Plan Formulary |
Anthem MediBlue Diabetes (HMO C-SNP)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
$7.50 | $15.00 | None | $718.80 |
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 |
Anthem MediBlue ESRD (HMO C-SNP)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
$7.50 | $15.00 | None | $718.80 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$32.00 |
$435 | No | 4 |
Tier 4 |
$95.00 | $285.00 | None | $553.80 |
Browse Plan Formulary |
Anthem MediBlue Heart (HMO C-SNP)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
$7.50 | $15.00 | None | $718.80 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$95.00 | $285.00 | None | $568.20 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$95.00 | $190.00 | None | $584.40 |
Browse Plan Formulary |
Anthem MediBlue StartSmart Plus (HMO)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
$14.50 | $29.00 | None | $718.80 |
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 |
Anthem MediBlue Value Plus (HMO)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
$9.50 | $19.00 | None | $718.80 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$95.00 | $237.50 | None | $1,027.80 |
Browse Plan Formulary |
Blue Shield Inspire (HMO)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$90.00 | $225.00 | None | $1,027.80 |
Browse Plan Formulary |
Blue Shield Promise AdvantageOptimum Plan (HMO)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
$3.00 | $7.50 | None | $1,027.80 |
Browse Plan Formulary |
Blue Shield Promise Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
0% | 0% | None | $1,027.80 |
Browse Plan Formulary |
Blue Shield Promise Coordinated Choice Plan (HMO)
|
$32.00 |
$435 | No | 2 |
Tier 2 |
25% | 25% | None | $1,027.80 |
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 |
Blue Shield Promise Coordinated Choice Plan (HMO)
|
$32.00 |
$435 | No | 2 |
Tier 2 |
25% | 25% | None | $1,027.80 |
Browse Plan Formulary |
Blue Shield Promise TotalDual Plan (HMO D-SNP)
|
$32.00 |
$435 | No | 2 |
Tier 2 |
25% | 25% | None | $1,027.80 |
Browse Plan Formulary |
Blue Shield Promise TotalDual Plan (HMO D-SNP)
|
$32.00 |
$435 | No | 2 |
Tier 2 |
25% | 25% | None | $1,027.80 |
Browse Plan Formulary |
Blue Shield Vital (HMO)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$95.00 | $237.50 | None | $1,027.80 |
Browse Plan Formulary |
Central Health Focus Plan (HMO C-SNP)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$75.00 | $150.00 | None | $449.40 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO D-SNP)
|
$32.00 |
$435 | No | 4 |
Tier 4 |
25% | 25% | None | $449.40 |
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 Medi-Medi Plan (HMO D-SNP)
|
$32.00 |
$435 | No | 4 |
Tier 4 |
25% | 25% | None | $449.40 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$75.00 | $150.00 | None | $449.40 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$32.00 |
$435 | No | 4 |
Tier 4 |
25% | 25% | None | $449.40 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$32.00 |
$435 | No | 4 |
Tier 4 |
25% | 25% | None | $449.40 |
Browse Plan Formulary |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$32.00 |
$0 | No | 1 |
Tier 1 |
0% | 0% | None | $390.00 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$90.00 | $260.00 | None | $518.40 |
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)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$90.00 | $260.00 | None | $519.60 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$90.00 | $260.00 | None | $518.40 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$90.00 | $260.00 | None | $519.60 |
Browse Plan Formulary |
Health Net Jade (HMO C-SNP)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$90.00 | $260.00 | None | $518.40 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO D-SNP)
|
$32.00 |
$350 | No | 4 |
Tier 4 |
$100.00 | $300.00 | None | $403.20 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO D-SNP)
|
$32.00 |
$350 | No | 4 |
Tier 4 |
$100.00 | $300.00 | None | $403.20 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Health Net Seniority Plus Amber II (HMO D-SNP)
|
$32.00 |
$350 | No | 4 |
Tier 4 |
$100.00 | $300.00 | None | $403.20 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO D-SNP)
|
$32.00 |
$350 | No | 4 |
Tier 4 |
$100.00 | $300.00 | None | $403.20 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$32.00 |
$370 | No | 4 |
Tier 4 |
$100.00 | $300.00 | None | $403.20 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$32.00 |
$370 | No | 4 |
Tier 4 |
$100.00 | $300.00 | None | $402.60 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$32.00 |
$370 | No | 4 |
Tier 4 |
$100.00 | $300.00 | None | $402.60 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier II (HMO)
|
$32.00 |
$410 | No | 4 |
Tier 4 |
$100.00 | $300.00 | None | $402.60 |
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)
|
$32.00 |
$410 | No | 4 |
Tier 4 |
$100.00 | $300.00 | None | $402.60 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$100.00 | $200.00 | None | $592.80 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$32.00 |
$435 | No | 4 |
Tier 4 |
$100.00 | $290.00 | None | $592.80 |
Browse Plan Formulary |
Imperial Senior Value (HMO C-SNP)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$90.00 | $180.00 | P | $823.80 |
Browse Plan Formulary |
Imperial Traditional (HMO) (HMO)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$90.00 | $180.00 | P | $823.80 |
Browse Plan Formulary |
Imperial Traditional Plus (HMO) (HMO)
|
$32.00 |
$435 | No | 4 |
Tier 4 |
25% | 25% | P | $823.80 |
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 |
Imperial Traditional Plus (HMO) (HMO)
|
$32.00 |
$435 | No | 4 |
Tier 4 |
25% | 25% | P | $823.80 |
Browse Plan Formulary |
Inter Valley Health Plan Vitality Plus (HMO)
|
$32.00 |
$435 | No | 2 |
Tier 2 |
25% | 25% | None | $511.20 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
$15.00 | $30.00 | None | $552.00 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
$15.00 | $30.00 | None | $534.00 |
Browse Plan Formulary |
L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$32.00 |
$0 | No | 1 |
Tier 1 |
0% | 0% | None | $516.00 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$32.00 |
$0 | No | 1 |
Tier 1 |
0% | 0% | None | $566.40 |
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 |
Molina Medicare Complete Care (HMO D-SNP)
|
$32.00 |
$435 | No | 4 |
Tier 4 |
33% | 33% | None | $685.80 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$32.00 |
$435 | No | 4 |
Tier 4 |
33% | 33% | None | $685.80 |
Browse Plan Formulary |
PHP (HMO C-SNP)
|
$32.00 |
$435 | No | 1 |
Tier 1 |
25% | n/a | None | $449.40 |
Browse Plan Formulary |
SCAN Balance (HMO C-SNP)
|
$32.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Tier 4 |
$95.00 | $265.00 | None | $681.60 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$95.00 | $265.00 | None | $675.60 |
Browse Plan Formulary |
SCAN Classic II (HMO)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$95.00 | $265.00 | None | $675.60 |
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 D-SNP)
|
$32.00 |
$435 | No | 4 |
Tier 4 |
25% | 25% | None | $669.60 |
Browse Plan Formulary |
SCAN Connections (HMO D-SNP)
|
$32.00 |
$435 | No | 4 |
Tier 4 |
25% | 25% | None | $669.60 |
Browse Plan Formulary |
SCAN Connections at Home (HMO D-SNP)
|
$32.00 |
$435 | No | 4 |
Tier 4 |
25% | 25% | None | $675.60 |
Browse Plan Formulary |
SCAN Connections at Home (HMO D-SNP)
|
$32.00 |
$435 | No | 4 |
Tier 4 |
25% | 25% | None | $675.60 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO I-SNP)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$95.00 | $285.00 | None | $676.20 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$32.00 |
$435 | No | 4 |
Tier 4 |
25% | 25% | None | $676.80 |
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 |
SCAN Plus (HMO)
|
$32.00 |
$435 | No | 4 |
Tier 4 |
25% | 25% | None | $676.80 |
Browse Plan Formulary |
SCAN Prime (HMO)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$95.00 | $265.00 | None | $675.60 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP)
|
$32.00 |
$435 | No | 2 |
Tier 2 |
15% | 15% | None | $552.00 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Assure (HMO)
|
$32.00 |
$435 | No | 4 |
Tier 4 |
25% | 25% | None | $503.40 |
Browse Plan Formulary |
VillageHealth (HMO-POS C-SNP)
|
$32.00 |
$435 | No | 4 |
Tier 4 |
25% | 25% | None | $681.60 |
Browse Plan Formulary |
VillageHealth (HMO-POS C-SNP)
|
$32.00 |
$435 | No | 4 |
Tier 4 |
25% | 25% | None | $681.60 |
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 |
WellCare Best (HMO)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
$0.00 | $0.00 | None | $623.40 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
$10.00 | $0.00 | None | $625.80 |
Browse Plan Formulary |
WellCare Freedom (HMO D-SNP)
|
$32.00 |
$435 | No | 4 |
Tier 4 |
50% | 50% | None | $630.00 |
Browse Plan Formulary |
WellCare Plus (HMO)
|
$32.00 |
$435 | No | 4 |
Tier 4 |
50% | 50% | None | $630.00 |
Browse Plan Formulary |
SCAN Classic II (HMO)
|
$39.00 |
$0 | No | 4 |
Tier 4 |
$95.00 | $265.00 | None | $675.60 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$98.00 |
$0 | No | 4 |
Tier 4 |
$100.00 | $300.00 | None | $241.80 |
Browse Plan Formulary |