CROMOLYN 20 MG/2 ML NEB SOLN AMPUL-NEB [Intal] (120 mls ) (NDC: 69784020560)
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 | 3 |
Tier 3 |
$47.00 | $131.00 | P | $963.60 |
Browse Plan Formulary |
AARP Medicare Advantage SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 | No | 3 |
Tier 3 |
$47.00 | $131.00 | P | $963.60 |
Browse Plan Formulary |
AARP Medicare Advantage SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 | No | 3 |
Tier 3 |
$47.00 | $131.00 | P | $963.60 |
Browse Plan Formulary |
Aetna Medicare Plus Plan (HMO)
|
$0.00 |
$0 | No | 3 |
Tier 3 |
$42.00 | $126.00 | P | $578.40 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 | No | 3 |
Tier 3 |
$47.00 | $141.00 | P | $578.40 |
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 | 3 |
Tier 3 |
$47.00 | $141.00 | P | $578.40 |
Browse Plan Formulary |
Alignment Health Plan Heart & Diabetes (HMO C-SNP)
|
$0.00 |
$0 | No | 3 |
Tier 3 |
$30.00 | $75.00 | P | $475.20 |
Browse Plan Formulary |
Alignment Health Plan My Choice (HMO)
|
$0.00 |
$0 | No | 3 |
Tier 3 |
$30.00 | $75.00 | P | $475.20 |
Browse Plan Formulary |
Alignment Health Plan Platinum (HMO)
|
$0.00 |
$0 | No | 3 |
Tier 3 |
$30.00 | $75.00 | P | $475.20 |
Browse Plan Formulary |
Alignment Health Plan smartHMO (HMO)
|
$0.00 |
$0 | No | 3 |
Tier 3 |
$30.00 | $75.00 | P | $475.20 |
Browse Plan Formulary |
Anthem Blue Cross Cal MediConnect (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No | 1 |
Tier 1 |
0% | 0% | P Q:240 /30Days | $970.80 |
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 Breathe (HMO C-SNP)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
$7.50 | $15.00 | P Q:240 /30Days | $972.00 |
Browse Plan Formulary |
Anthem MediBlue Care On Site (HMO I-SNP)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
$9.50 | $19.00 | P Q:240 /30Days | $972.00 |
Browse Plan Formulary |
Anthem MediBlue Connect (HMO D-SNP)
|
$0.00 |
$435* | No | 2* |
Tier 2 |
$0.00 | $0.00 | P Q:240 /30Days | $972.00 |
Browse Plan Formulary |
Anthem MediBlue Diabetes (HMO C-SNP)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
$7.50 | $15.00 | P Q:240 /30Days | $972.00 |
Browse Plan Formulary |
Anthem MediBlue ESRD (HMO C-SNP)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
$7.50 | $15.00 | P Q:240 /30Days | $972.00 |
Browse Plan Formulary |
Anthem MediBlue Heart (HMO C-SNP)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
$7.50 | $15.00 | P Q:240 /30Days | $972.00 |
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 |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
$15.00 | $45.00 | P Q:240 /30Days | $964.80 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
$5.00 | $0.00 | P Q:240 /30Days | $964.80 |
Browse Plan Formulary |
Anthem MediBlue StartSmart Plus (HMO)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
$14.50 | $29.00 | P Q:240 /30Days | $972.00 |
Browse Plan Formulary |
Anthem MediBlue Value Plus (HMO)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
$9.50 | $19.00 | P Q:240 /30Days | $972.00 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
$5.00 | $7.50 | P Q:240 /30Days | $867.60 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
$10.00 | $15.00 | P Q:240 /30Days | $867.60 |
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 |
Blue Shield Inspire (HMO)
|
$0.00 |
$0 | No | 3 |
Tier 3 |
$35.00 | $87.50 | P Q:240 /30Days | $867.60 |
Browse Plan Formulary |
Blue Shield Promise AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
$3.00 | $7.50 | P | $862.80 |
Browse Plan Formulary |
Blue Shield Promise Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
0% | 0% | P | $832.80 |
Browse Plan Formulary |
Blue Shield Vital (HMO)
|
$0.00 |
$0 | No | 3 |
Tier 3 |
$40.00 | $100.00 | P Q:240 /30Days | $867.60 |
Browse Plan Formulary |
Central Health Focus Plan (HMO C-SNP)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
$0.00 | $0.00 | P | $440.40 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
$0.00 | $0.00 | P | $440.40 |
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 | P | $445.20 |
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 | P | $445.20 |
Browse Plan Formulary |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No | 1 |
Tier 1 |
0% | 0% | P | $772.80 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 | No | 1 |
Tier 1 |
$0.00 | $0.00 | P | $874.80 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 | No | 1 |
Tier 1 |
$0.00 | $0.00 | P | $874.80 |
Browse Plan Formulary |
Health Net Jade (HMO C-SNP)
|
$0.00 |
$0 | No | 1 |
Tier 1 |
$0.00 | $0.00 | P | $874.80 |
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 |
Health Net Seniority Plus Sapphire (HMO)
|
$0.00 |
$370* | No | 1* |
Tier 1 |
$0.00 | $0.00 | P | $822.00 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 | No | 5 |
Tier 5 |
33% | n/a | P | $1,238.40 |
Browse Plan Formulary |
Imperial Senior Value (HMO C-SNP)
|
$0.00 |
$0 | No | 3 |
Tier 3 |
$45.00 | $90.00 | P | $778.80 |
Browse Plan Formulary |
Imperial Traditional (HMO) (HMO)
|
$0.00 |
$0 | No | 3 |
Tier 3 |
$45.00 | $90.00 | P | $778.80 |
Browse Plan Formulary |
Inter Valley Health Plan Service To Seniors (HMO)
|
$0.00 |
$0 | No | 3 |
Tier 3 |
$47.00 | $117.50 | P Q:240 /30Days | $572.40 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
$15.00 | $30.00 | P | $938.40 |
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 |
L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No | 1 |
Tier 1 |
0% | 0% | P | $654.00 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No | 1 |
Tier 1 |
0% | 0% | P | $842.40 |
Browse Plan Formulary |
PHP (HMO C-SNP)
|
$0.00 |
$435 | No | 1 |
Tier 1 |
25% | n/a | P | $440.40 |
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 | P | $813.60 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 | No | 4 |
Tier 4 |
$95.00 | $265.00 | P | $813.60 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO I-SNP)
|
$0.00 |
$0 | No | 4 |
Tier 4 |
$95.00 | $285.00 | P | $813.60 |
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)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
$0.00 | $0.00 | P | $1,094.40 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
$10.00 | $0.00 | P | $1,094.40 |
Browse Plan Formulary |
WellCare Plus (HMO)
|
$0.00 |
$435 | No | 3 |
Tier 3 |
$47.00 | $94.00 | P | $1,094.40 |
Browse Plan Formulary |
WellCare Freedom (HMO D-SNP)
|
$1.10 |
$435 | No | 3 |
Tier 3 |
$47.00 | $94.00 | P | $1,094.40 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$14.40 |
$435 | No | 2 |
Tier 2 |
$2.00 | $6.00 | P Q:240 /30Days | $964.80 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Assure (HMO)
|
$14.90 |
$435 | No | 3 |
Tier 3 |
25% | 25% | P | $963.60 |
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 |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$15.40 |
$0 | No | 2 |
Tier 2 |
$15.00 | $30.00 | P | $938.40 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$16.00 |
$0 | No | 1 |
Tier 1 |
$5.00 | $10.00 | P | $874.80 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$16.00 |
$0 | No | 1 |
Tier 1 |
$5.00 | $10.00 | P | $874.80 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$16.80 |
$435 | No | 5 |
Tier 5 |
25% | n/a | P | $1,238.40 |
Browse Plan Formulary |
AARP Medicare Advantage SecureHorizons Premier (HMO)
|
$18.70 |
$0 | No | 3 |
Tier 3 |
$47.00 | $131.00 | P | $963.60 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$20.20 |
$435 | No | 2 |
Tier 2 |
25% | 25% | P Q:240 /30Days | $972.00 |
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 |
SCAN Prime (HMO)
|
$25.00 |
$0 | No | 4 |
Tier 4 |
$95.00 | $265.00 | P | $813.60 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$25.30 |
$435 | No | 2 |
Tier 2 |
$15.00 | $45.00 | P Q:240 /30Days | $964.80 |
Browse Plan Formulary |
Alignment Health Plan CalPlus (HMO)
|
$27.30 |
$435 | No | 3 |
Tier 3 |
25% | 25% | P | $468.00 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP)
|
$31.10 |
$435 | No | 2 |
Tier 2 |
15% | 15% | P | $938.40 |
Browse Plan Formulary |
AARP Medicare Advantage SecureHorizons Focus (HMO)
|
$32.00 |
$0 | No | 3 |
Tier 3 |
$47.00 | $131.00 | P | $963.60 |
Browse Plan Formulary |
AARP Medicare Advantage SecureHorizons Plan 1 (HMO)
|
$32.00 |
$0 | No | 3 |
Tier 3 |
$47.00 | $131.00 | P | $963.60 |
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 | 3 |
Tier 3 |
$47.00 | $131.00 | P | $963.60 |
Browse Plan Formulary |
AARP Medicare Advantage SecureHorizons Premier (HMO)
|
$32.00 |
$0 | No | 3 |
Tier 3 |
$47.00 | $131.00 | P | $963.60 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$32.00 |
$0 | No | 3 |
Tier 3 |
$47.00 | $141.00 | P | $578.40 |
Browse Plan Formulary |
Aetna Medicare Plus Plan (HMO)
|
$32.00 |
$0 | No | 3 |
Tier 3 |
$42.00 | $126.00 | P | $578.40 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$32.00 |
$0 | No | 3 |
Tier 3 |
$47.00 | $141.00 | P | $578.40 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$32.00 |
$0 | No | 3 |
Tier 3 |
$47.00 | $141.00 | P | $578.40 |
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 | 3 |
Tier 3 |
25% | 25% | P | $468.00 |
Browse Plan Formulary |
Alignment Health Plan Heart & Diabetes (HMO C-SNP)
|
$32.00 |
$0 | No | 3 |
Tier 3 |
$30.00 | $75.00 | P | $475.20 |
Browse Plan Formulary |
Alignment Health Plan My Choice (HMO)
|
$32.00 |
$0 | No | 3 |
Tier 3 |
$30.00 | $75.00 | P | $475.20 |
Browse Plan Formulary |
Alignment Health Plan Platinum (HMO)
|
$32.00 |
$0 | No | 3 |
Tier 3 |
$30.00 | $75.00 | P | $475.20 |
Browse Plan Formulary |
Alignment Health Plan smartHMO (HMO)
|
$32.00 |
$0 | No | 3 |
Tier 3 |
$30.00 | $75.00 | P | $475.20 |
Browse Plan Formulary |
Anthem Blue Cross Cal MediConnect (Medicare-Medicaid Plan)
|
$32.00 |
$0 | No | 1 |
Tier 1 |
0% | 0% | P Q:240 /30Days | $970.80 |
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 Breathe (HMO C-SNP)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
$7.50 | $15.00 | P Q:240 /30Days | $972.00 |
Browse Plan Formulary |
Anthem MediBlue Care On Site (HMO I-SNP)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
$9.50 | $19.00 | P Q:240 /30Days | $972.00 |
Browse Plan Formulary |
Anthem MediBlue Connect (HMO D-SNP)
|
$32.00 |
$435* | No | 2* |
Tier 2 |
$0.00 | $0.00 | P Q:240 /30Days | $972.00 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$32.00 |
$435 | No | 2 |
Tier 2 |
25% | 25% | P Q:240 /30Days | $972.00 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$32.00 |
$435 | No | 2 |
Tier 2 |
$15.00 | $45.00 | P Q:240 /30Days | $964.80 |
Browse Plan Formulary |
Anthem MediBlue Diabetes (HMO C-SNP)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
$7.50 | $15.00 | P Q:240 /30Days | $972.00 |
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 |
Anthem MediBlue ESRD (HMO C-SNP)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
$7.50 | $15.00 | P Q:240 /30Days | $972.00 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$32.00 |
$435 | No | 2 |
Tier 2 |
$2.00 | $6.00 | P Q:240 /30Days | $964.80 |
Browse Plan Formulary |
Anthem MediBlue Heart (HMO C-SNP)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
$7.50 | $15.00 | P Q:240 /30Days | $972.00 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
$15.00 | $45.00 | P Q:240 /30Days | $964.80 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
$5.00 | $0.00 | P Q:240 /30Days | $964.80 |
Browse Plan Formulary |
Anthem MediBlue StartSmart Plus (HMO)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
$14.50 | $29.00 | P Q:240 /30Days | $972.00 |
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 |
Anthem MediBlue Value Plus (HMO)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
$9.50 | $19.00 | P Q:240 /30Days | $972.00 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
$5.00 | $7.50 | P Q:240 /30Days | $867.60 |
Browse Plan Formulary |
Blue Shield Inspire (HMO)
|
$32.00 |
$0 | No | 3 |
Tier 3 |
$35.00 | $87.50 | P Q:240 /30Days | $867.60 |
Browse Plan Formulary |
Blue Shield Promise AdvantageOptimum Plan (HMO)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
$3.00 | $7.50 | P | $862.80 |
Browse Plan Formulary |
Blue Shield Promise Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
0% | 0% | P | $832.80 |
Browse Plan Formulary |
Blue Shield Promise Coordinated Choice Plan (HMO)
|
$32.00 |
$435 | No | 2 |
Tier 2 |
25% | 25% | P | $832.80 |
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% | P | $832.80 |
Browse Plan Formulary |
Blue Shield Promise TotalDual Plan (HMO D-SNP)
|
$32.00 |
$435 | No | 2 |
Tier 2 |
25% | 25% | P | $832.80 |
Browse Plan Formulary |
Blue Shield Promise TotalDual Plan (HMO D-SNP)
|
$32.00 |
$435 | No | 2 |
Tier 2 |
25% | 25% | P | $832.80 |
Browse Plan Formulary |
Blue Shield Vital (HMO)
|
$32.00 |
$0 | No | 3 |
Tier 3 |
$40.00 | $100.00 | P Q:240 /30Days | $867.60 |
Browse Plan Formulary |
Central Health Focus Plan (HMO C-SNP)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
$0.00 | $0.00 | P | $440.40 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO D-SNP)
|
$32.00 |
$435* | No | 2* |
Tier 2 |
$0.00 | $0.00 | P | $440.40 |
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 | 2* |
Tier 2 |
$0.00 | $0.00 | P | $440.40 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
$0.00 | $0.00 | P | $440.40 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$32.00 |
$435* | No | 2* |
Tier 2 |
$0.00 | $0.00 | P | $440.40 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$32.00 |
$435* | No | 2* |
Tier 2 |
$0.00 | $0.00 | P | $440.40 |
Browse Plan Formulary |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$32.00 |
$0 | No | 1 |
Tier 1 |
0% | 0% | P | $772.80 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$32.00 |
$0 | No | 1 |
Tier 1 |
$0.00 | $0.00 | P | $874.80 |
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 |
Health Net Gold Select (HMO)
|
$32.00 |
$0 | No | 1 |
Tier 1 |
$0.00 | $0.00 | P | $874.80 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$32.00 |
$0 | No | 1 |
Tier 1 |
$5.00 | $10.00 | P | $874.80 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$32.00 |
$0 | No | 1 |
Tier 1 |
$5.00 | $10.00 | P | $874.80 |
Browse Plan Formulary |
Health Net Jade (HMO C-SNP)
|
$32.00 |
$0 | No | 1 |
Tier 1 |
$0.00 | $0.00 | P | $874.80 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO D-SNP)
|
$32.00 |
$350* | No | 1* |
Tier 1 |
$0.00 | $0.00 | P | $822.00 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO D-SNP)
|
$32.00 |
$350* | No | 1* |
Tier 1 |
$0.00 | $0.00 | P | $822.00 |
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 |
Health Net Seniority Plus Amber II (HMO D-SNP)
|
$32.00 |
$350* | No | 1* |
Tier 1 |
$0.00 | $0.00 | P | $822.00 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO D-SNP)
|
$32.00 |
$350* | No | 1* |
Tier 1 |
$0.00 | $0.00 | P | $822.00 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$32.00 |
$370* | No | 1* |
Tier 1 |
$0.00 | $0.00 | P | $822.00 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$32.00 |
$370* | No | 1* |
Tier 1 |
$0.00 | $0.00 | P | $822.00 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$32.00 |
$370* | No | 1* |
Tier 1 |
$0.00 | $0.00 | P | $822.00 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier II (HMO)
|
$32.00 |
$410* | No | 1* |
Tier 1 |
$0.00 | $0.00 | P | $822.00 |
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 |
Health Net Seniority Plus Sapphire Premier II (HMO)
|
$32.00 |
$410* | No | 1* |
Tier 1 |
$0.00 | $0.00 | P | $822.00 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$32.00 |
$0 | No | 5 |
Tier 5 |
33% | n/a | P | $1,238.40 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$32.00 |
$435 | No | 5 |
Tier 5 |
25% | n/a | P | $1,238.40 |
Browse Plan Formulary |
Imperial Senior Value (HMO C-SNP)
|
$32.00 |
$0 | No | 3 |
Tier 3 |
$45.00 | $90.00 | P | $778.80 |
Browse Plan Formulary |
Imperial Traditional (HMO) (HMO)
|
$32.00 |
$0 | No | 3 |
Tier 3 |
$45.00 | $90.00 | P | $778.80 |
Browse Plan Formulary |
Imperial Traditional Plus (HMO) (HMO)
|
$32.00 |
$435 | No | 3 |
Tier 3 |
25% | 25% | P | $778.80 |
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 | 3 |
Tier 3 |
25% | 25% | P | $778.80 |
Browse Plan Formulary |
Inter Valley Health Plan Vitality Plus (HMO)
|
$32.00 |
$435 | No | 2 |
Tier 2 |
25% | 25% | P Q:240 /30Days | $572.40 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
$15.00 | $30.00 | P | $938.40 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
$15.00 | $30.00 | P | $938.40 |
Browse Plan Formulary |
L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$32.00 |
$0 | No | 1 |
Tier 1 |
0% | 0% | P | $654.00 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$32.00 |
$0 | No | 1 |
Tier 1 |
0% | 0% | P | $842.40 |
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 | 3 |
Tier 3 |
$40.00 | $120.00 | P | $1,009.20 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$32.00 |
$435 | No | 3 |
Tier 3 |
$40.00 | $120.00 | P | $1,009.20 |
Browse Plan Formulary |
PHP (HMO C-SNP)
|
$32.00 |
$435 | No | 1 |
Tier 1 |
25% | n/a | P | $440.40 |
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 | P | $813.60 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$95.00 | $265.00 | P | $813.60 |
Browse Plan Formulary |
SCAN Classic II (HMO)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$95.00 | $265.00 | P | $813.60 |
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% | P | $813.60 |
Browse Plan Formulary |
SCAN Connections (HMO D-SNP)
|
$32.00 |
$435 | No | 4 |
Tier 4 |
25% | 25% | P | $813.60 |
Browse Plan Formulary |
SCAN Connections at Home (HMO D-SNP)
|
$32.00 |
$435 | No | 4 |
Tier 4 |
25% | 25% | P | $813.60 |
Browse Plan Formulary |
SCAN Connections at Home (HMO D-SNP)
|
$32.00 |
$435 | No | 4 |
Tier 4 |
25% | 25% | P | $813.60 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO I-SNP)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$95.00 | $285.00 | P | $813.60 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$32.00 |
$435 | No | 4 |
Tier 4 |
25% | 25% | P | $813.60 |
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 Plus (HMO)
|
$32.00 |
$435 | No | 4 |
Tier 4 |
25% | 25% | P | $813.60 |
Browse Plan Formulary |
SCAN Prime (HMO)
|
$32.00 |
$0 | No | 4 |
Tier 4 |
$95.00 | $265.00 | P | $813.60 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP)
|
$32.00 |
$435 | No | 2 |
Tier 2 |
15% | 15% | P | $938.40 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Assure (HMO)
|
$32.00 |
$435 | No | 3 |
Tier 3 |
25% | 25% | P | $963.60 |
Browse Plan Formulary |
VillageHealth (HMO-POS C-SNP)
|
$32.00 |
$435 | No | 4 |
Tier 4 |
25% | 25% | P | $813.60 |
Browse Plan Formulary |
VillageHealth (HMO-POS C-SNP)
|
$32.00 |
$435 | No | 4 |
Tier 4 |
25% | 25% | P | $813.60 |
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 | P | $1,094.40 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$32.00 |
$0 | No | 2 |
Tier 2 |
$10.00 | $0.00 | P | $1,094.40 |
Browse Plan Formulary |
WellCare Freedom (HMO D-SNP)
|
$32.00 |
$435 | No | 3 |
Tier 3 |
$47.00 | $94.00 | P | $1,094.40 |
Browse Plan Formulary |
WellCare Plus (HMO)
|
$32.00 |
$435 | No | 3 |
Tier 3 |
$47.00 | $94.00 | P | $1,094.40 |
Browse Plan Formulary |
SCAN Classic II (HMO)
|
$39.00 |
$0 | No | 4 |
Tier 4 |
$95.00 | $265.00 | P | $813.60 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$98.00 |
$0 | No | 3 |
Tier 3 |
$47.00 | $141.00 | P | $578.40 |
Browse Plan Formulary |