AMBRISENTAN 10 MG TABLET [LETAIRIS] (10 TABLETs ) (NDC: 70710118003)
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 |
5 |
Tier 5 |
33% | 33% | P Q:30 /30Days | $6,502.80 |
Browse Plan Formulary |
AARP Medicare Advantage SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | 33% | P Q:30 /30Days | $6,502.80 |
Browse Plan Formulary |
AARP Medicare Advantage SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | 33% | P Q:30 /30Days | $6,502.80 |
Browse Plan Formulary |
Aetna Medicare Plus Plan (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $2,305.80 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $2,305.80 |
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 |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $2,305.80 |
Browse Plan Formulary |
Alignment Health Plan Heart & Diabetes (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $3,531.30 |
Browse Plan Formulary |
Alignment Health Plan My Choice (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $3,531.30 |
Browse Plan Formulary |
Alignment Health Plan Platinum (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $3,531.30 |
Browse Plan Formulary |
Alignment Health Plan smartHMO (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $3,531.30 |
Browse Plan Formulary |
Anthem Blue Cross Cal MediConnect (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | P Q:30 /30Days | $7,056.90 |
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 |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $7,755.60 |
Browse Plan Formulary |
Anthem MediBlue Care On Site (HMO I-SNP)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $7,755.60 |
Browse Plan Formulary |
Anthem MediBlue Connect (HMO D-SNP)
|
$0.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:30 /30Days | $7,755.60 |
Browse Plan Formulary |
Anthem MediBlue Diabetes (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $7,755.60 |
Browse Plan Formulary |
Anthem MediBlue ESRD (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $7,755.60 |
Browse Plan Formulary |
Anthem MediBlue Heart (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $7,755.60 |
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 |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $7,494.00 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $7,494.00 |
Browse Plan Formulary |
Anthem MediBlue StartSmart Plus (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $7,755.60 |
Browse Plan Formulary |
Anthem MediBlue Value Plus (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $7,755.60 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:1 /1Days | $5,166.90 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:1 /1Days | $5,166.90 |
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 |
5 |
Tier 5 |
33% | n/a | P Q:1 /1Days | $5,166.90 |
Browse Plan Formulary |
Blue Shield Promise AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:1 /1Days | $5,157.00 |
Browse Plan Formulary |
Blue Shield Promise Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | P Q:1 /1Days | $4,931.10 |
Browse Plan Formulary |
Blue Shield Vital (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:1 /1Days | $5,166.90 |
Browse Plan Formulary |
Central Health Focus Plan (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $7,503.00 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $7,503.00 |
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 |
Connected Care (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Tier 5 |
33% | 15% | P Q:30 /30Days | $7,524.90 |
Browse Plan Formulary |
Connected Care Select (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Tier 5 |
33% | 15% | P Q:30 /30Days | $7,524.90 |
Browse Plan Formulary |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
1 |
Tier 1 |
0% | 0% | None | $4,283.40 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $4,674.90 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $4,674.90 |
Browse Plan Formulary |
Health Net Jade (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $4,674.90 |
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 |
5 |
Tier 5 |
26% | n/a | None | $4,556.70 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $2,850.00 |
Browse Plan Formulary |
Imperial Senior Value (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $8,603.40 |
Browse Plan Formulary |
Imperial Traditional (HMO) (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $8,603.40 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
$15.00 | $30.00 | None | $6,049.50 |
Browse Plan Formulary |
L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
1 |
Tier 1 |
0% | 0% | P Q:30 /30Days | $3,007.20 |
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 |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | P Q:30 /30Days | $4,394.70 |
Browse Plan Formulary |
PHP (HMO C-SNP)
|
$0.00 |
$435 |
No |
4 |
Tier 4 |
25% | n/a | P Q:30 /30Days | $7,505.70 |
Browse Plan Formulary |
SCAN Balance (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Tier 5 |
33% | n/a | P | $7,111.80 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P | $7,111.80 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO I-SNP)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P | $7,111.80 |
Browse Plan Formulary |
WellCare Best (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $4,909.50 |
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 Dividend (HMO)
|
$0.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $4,909.50 |
Browse Plan Formulary |
WellCare Plus (HMO)
|
$0.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:30 /30Days | $4,909.50 |
Browse Plan Formulary |
WellCare Freedom (HMO D-SNP)
|
$1.10 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:30 /30Days | $4,909.50 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$14.40 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:30 /30Days | $7,494.00 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Assure (HMO)
|
$14.90 |
$435 |
No |
5 |
Tier 5 |
25% | 25% | P Q:30 /30Days | $6,502.80 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$15.40 |
$0 |
No |
2 |
Tier 2 |
$15.00 | $30.00 | None | $6,049.50 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Health Net Healthy Heart (HMO)
|
$16.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $4,674.90 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$16.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $4,674.90 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$16.80 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:30 /30Days | $2,850.00 |
Browse Plan Formulary |
AARP Medicare Advantage SecureHorizons Premier (HMO)
|
$18.70 |
$0 |
No |
5 |
Tier 5 |
33% | 33% | P Q:30 /30Days | $6,502.80 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$20.20 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:30 /30Days | $7,755.60 |
Browse Plan Formulary |
SCAN Prime (HMO)
|
$25.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P | $7,111.80 |
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 Coordination Plus (HMO)
|
$25.30 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:30 /30Days | $7,494.00 |
Browse Plan Formulary |
Alignment Health Plan CalPlus (HMO)
|
$27.30 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:30 /30Days | $3,524.40 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP)
|
$31.10 |
$435 |
No |
2 |
Tier 2 |
15% | 15% | None | $6,049.50 |
Browse Plan Formulary |
AARP Medicare Advantage SecureHorizons Focus (HMO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | 33% | P Q:30 /30Days | $6,502.80 |
Browse Plan Formulary |
AARP Medicare Advantage SecureHorizons Plan 1 (HMO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | 33% | P Q:30 /30Days | $6,502.80 |
Browse Plan Formulary |
AARP Medicare Advantage SecureHorizons Plan 2 (HMO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | 33% | P Q:30 /30Days | $6,502.80 |
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 |
AARP Medicare Advantage SecureHorizons Premier (HMO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | 33% | P Q:30 /30Days | $6,502.80 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $2,305.80 |
Browse Plan Formulary |
Aetna Medicare Plus Plan (HMO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $2,305.80 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $2,305.80 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $2,305.80 |
Browse Plan Formulary |
Alignment Health Plan CalPlus (HMO)
|
$32.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:30 /30Days | $3,524.40 |
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 Heart & Diabetes (HMO C-SNP)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $3,531.30 |
Browse Plan Formulary |
Alignment Health Plan My Choice (HMO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $3,531.30 |
Browse Plan Formulary |
Alignment Health Plan Platinum (HMO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $3,531.30 |
Browse Plan Formulary |
Alignment Health Plan smartHMO (HMO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $3,531.30 |
Browse Plan Formulary |
Anthem Blue Cross Cal MediConnect (Medicare-Medicaid Plan)
|
$32.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | P Q:30 /30Days | $7,056.90 |
Browse Plan Formulary |
Anthem MediBlue Breathe (HMO C-SNP)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $7,755.60 |
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 |
Anthem MediBlue Care On Site (HMO I-SNP)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $7,755.60 |
Browse Plan Formulary |
Anthem MediBlue Connect (HMO D-SNP)
|
$32.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:30 /30Days | $7,755.60 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$32.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:30 /30Days | $7,755.60 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$32.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:30 /30Days | $7,494.00 |
Browse Plan Formulary |
Anthem MediBlue Diabetes (HMO C-SNP)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $7,755.60 |
Browse Plan Formulary |
Anthem MediBlue ESRD (HMO C-SNP)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $7,755.60 |
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 |
Anthem MediBlue Extra (HMO)
|
$32.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:30 /30Days | $7,494.00 |
Browse Plan Formulary |
Anthem MediBlue Heart (HMO C-SNP)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $7,755.60 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $7,494.00 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $7,494.00 |
Browse Plan Formulary |
Anthem MediBlue StartSmart Plus (HMO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $7,755.60 |
Browse Plan Formulary |
Anthem MediBlue Value Plus (HMO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $7,755.60 |
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 65 Plus (HMO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:1 /1Days | $5,166.90 |
Browse Plan Formulary |
Blue Shield Inspire (HMO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:1 /1Days | $5,166.90 |
Browse Plan Formulary |
Blue Shield Promise AdvantageOptimum Plan (HMO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:1 /1Days | $5,157.00 |
Browse Plan Formulary |
Blue Shield Promise Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$32.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | P Q:1 /1Days | $4,931.10 |
Browse Plan Formulary |
Blue Shield Promise Coordinated Choice Plan (HMO)
|
$32.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:1 /1Days | $4,931.10 |
Browse Plan Formulary |
Blue Shield Promise Coordinated Choice Plan (HMO)
|
$32.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:1 /1Days | $4,931.10 |
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 TotalDual Plan (HMO D-SNP)
|
$32.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:1 /1Days | $4,931.10 |
Browse Plan Formulary |
Blue Shield Promise TotalDual Plan (HMO D-SNP)
|
$32.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:1 /1Days | $4,931.10 |
Browse Plan Formulary |
Blue Shield Vital (HMO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:1 /1Days | $5,166.90 |
Browse Plan Formulary |
Central Health Focus Plan (HMO C-SNP)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $7,503.00 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO D-SNP)
|
$32.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:30 /30Days | $7,503.00 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO D-SNP)
|
$32.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:30 /30Days | $7,503.00 |
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 |
Central Health Medicare Plan (HMO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $7,503.00 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$32.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:30 /30Days | $7,503.00 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$32.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:30 /30Days | $7,503.00 |
Browse Plan Formulary |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$32.00 |
$0 |
No |
1 |
Tier 1 |
0% | 0% | None | $4,283.40 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $4,674.90 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $4,674.90 |
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)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $4,674.90 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $4,674.90 |
Browse Plan Formulary |
Health Net Jade (HMO C-SNP)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | None | $4,674.90 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO D-SNP)
|
$32.00 |
$350 |
No |
5 |
Tier 5 |
26% | n/a | None | $4,556.70 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO D-SNP)
|
$32.00 |
$350 |
No |
5 |
Tier 5 |
26% | n/a | None | $4,556.70 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO D-SNP)
|
$32.00 |
$350 |
No |
5 |
Tier 5 |
26% | n/a | None | $4,556.70 |
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 |
5 |
Tier 5 |
26% | n/a | None | $4,556.70 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$32.00 |
$370 |
No |
5 |
Tier 5 |
26% | n/a | None | $4,556.70 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$32.00 |
$370 |
No |
5 |
Tier 5 |
26% | n/a | None | $4,556.70 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier (HMO)
|
$32.00 |
$370 |
No |
5 |
Tier 5 |
26% | n/a | None | $4,556.70 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier II (HMO)
|
$32.00 |
$410 |
No |
5 |
Tier 5 |
25% | n/a | None | $4,556.70 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire Premier II (HMO)
|
$32.00 |
$410 |
No |
5 |
Tier 5 |
25% | n/a | None | $4,556.70 |
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 Gold Plus H5619-021 (HMO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $2,850.00 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$32.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:30 /30Days | $2,850.00 |
Browse Plan Formulary |
Imperial Senior Value (HMO C-SNP)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $8,603.40 |
Browse Plan Formulary |
Imperial Traditional (HMO) (HMO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $8,603.40 |
Browse Plan Formulary |
Imperial Traditional Plus (HMO) (HMO)
|
$32.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:30 /30Days | $8,603.40 |
Browse Plan Formulary |
Imperial Traditional Plus (HMO) (HMO)
|
$32.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:30 /30Days | $8,603.40 |
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)
|
$32.00 |
$0 |
No |
2 |
Tier 2 |
$15.00 | $30.00 | None | $6,049.50 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$32.00 |
$0 |
No |
2 |
Tier 2 |
$15.00 | $30.00 | None | $6,049.50 |
Browse Plan Formulary |
L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$32.00 |
$0 |
No |
1 |
Tier 1 |
0% | 0% | P Q:30 /30Days | $3,007.20 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$32.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | P Q:30 /30Days | $4,394.70 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$32.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:30 /30Days | $4,169.70 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$32.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:30 /30Days | $4,169.70 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
PHP (HMO C-SNP)
|
$32.00 |
$435 |
No |
4 |
Tier 4 |
25% | n/a | P Q:30 /30Days | $7,505.70 |
Browse Plan Formulary |
SCAN Balance (HMO C-SNP)
|
$32.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Tier 5 |
33% | n/a | P | $7,111.80 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P | $7,111.80 |
Browse Plan Formulary |
SCAN Classic II (HMO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P | $7,111.80 |
Browse Plan Formulary |
SCAN Connections (HMO D-SNP)
|
$32.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P | $7,111.80 |
Browse Plan Formulary |
SCAN Connections (HMO D-SNP)
|
$32.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P | $7,111.80 |
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 Connections at Home (HMO D-SNP)
|
$32.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P | $7,111.80 |
Browse Plan Formulary |
SCAN Connections at Home (HMO D-SNP)
|
$32.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P | $7,111.80 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO I-SNP)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P | $7,111.80 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$32.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P | $7,111.80 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$32.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P | $7,111.80 |
Browse Plan Formulary |
SCAN Prime (HMO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P | $7,111.80 |
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 |
Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP)
|
$32.00 |
$435 |
No |
2 |
Tier 2 |
15% | 15% | None | $6,049.50 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Assure (HMO)
|
$32.00 |
$435 |
No |
5 |
Tier 5 |
25% | 25% | P Q:30 /30Days | $6,502.80 |
Browse Plan Formulary |
VillageHealth (HMO-POS C-SNP)
|
$32.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P | $7,111.80 |
Browse Plan Formulary |
VillageHealth (HMO-POS C-SNP)
|
$32.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P | $7,111.80 |
Browse Plan Formulary |
WellCare Best (HMO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $4,909.50 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$32.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $4,909.50 |
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 Freedom (HMO D-SNP)
|
$32.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:30 /30Days | $4,909.50 |
Browse Plan Formulary |
WellCare Plus (HMO)
|
$32.00 |
$435 |
No |
5 |
Tier 5 |
25% | n/a | P Q:30 /30Days | $4,909.50 |
Browse Plan Formulary |
SCAN Classic II (HMO)
|
$39.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P | $7,111.80 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$98.00 |
$0 |
No |
5 |
Tier 5 |
33% | n/a | P Q:30 /30Days | $2,305.80 |
Browse Plan Formulary |