Atovaquone-Proguanil 250; 100mg/1; mg/1 [Malarone] (NDC: 68462040467)
2021 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 Freedom Plus (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $90.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Freedom Plus (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $90.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage SecureHorizons Focus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $90.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage SecureHorizons Focus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $90.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $90.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
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 1 (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $90.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $90.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $90.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Plus Plan (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$99.00 | $297.00 | None | $126.90 |
Browse Plan Formulary |
Aetna Medicare Plus Plan (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$99.00 | $297.00 | None | $126.90 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $97.50 |
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 |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $97.50 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $97.50 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $97.50 |
Browse Plan Formulary |
Anthem Blue Cross Cal MediConnect (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | None | $44.10 |
Browse Plan Formulary |
Anthem Blue Cross Cal MediConnect (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | None | $44.10 |
Browse Plan Formulary |
Anthem MediBlue Care On Site (HMO I-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$9.50 | $19.00 | None | $138.00 |
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 Care On Site (HMO I-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$9.50 | $19.00 | None | $138.00 |
Browse Plan Formulary |
Anthem MediBlue Diabetes Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$7.50 | $15.00 | None | $138.00 |
Browse Plan Formulary |
Anthem MediBlue Diabetes Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$7.50 | $15.00 | None | $138.00 |
Browse Plan Formulary |
Anthem MediBlue ESRD Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$7.50 | $15.00 | None | $138.00 |
Browse Plan Formulary |
Anthem MediBlue ESRD Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$7.50 | $15.00 | None | $138.00 |
Browse Plan Formulary |
Anthem MediBlue Heart Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$7.50 | $15.00 | None | $138.00 |
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 Heart Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$7.50 | $15.00 | None | $138.00 |
Browse Plan Formulary |
Anthem MediBlue Lung Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$7.50 | $15.00 | None | $138.00 |
Browse Plan Formulary |
Anthem MediBlue Lung Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$7.50 | $15.00 | None | $138.00 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$15.00 | $45.00 | None | $86.40 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$15.00 | $45.00 | None | $86.40 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $0.00 | None | $86.40 |
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 |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $0.00 | None | $86.40 |
Browse Plan Formulary |
Anthem MediBlue StartSmart Plus (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$14.50 | $29.00 | None | $138.00 |
Browse Plan Formulary |
Anthem MediBlue StartSmart Plus (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$14.50 | $29.00 | None | $138.00 |
Browse Plan Formulary |
Anthem MediBlue Value Plus (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$9.50 | $19.00 | None | $138.00 |
Browse Plan Formulary |
Anthem MediBlue Value Plus (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$9.50 | $19.00 | None | $138.00 |
Browse Plan Formulary |
AVA (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $150.00 |
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 |
AVA (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $150.00 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $7.50 | None | $110.40 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $7.50 | None | $110.40 |
Browse Plan Formulary |
Blue Shield 65 Plus Plan 2 (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$10.00 | $15.00 | None | $111.90 |
Browse Plan Formulary |
Blue Shield 65 Plus Plan 2 (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$10.00 | $15.00 | None | $111.90 |
Browse Plan Formulary |
Blue Shield AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$40.00 | $100.00 | None | $110.40 |
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 |
Blue Shield AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$40.00 | $100.00 | None | $110.40 |
Browse Plan Formulary |
Blue Shield Inspire (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$3.00 | $4.50 | None | $110.40 |
Browse Plan Formulary |
Blue Shield Inspire (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$3.00 | $4.50 | None | $110.40 |
Browse Plan Formulary |
Blue Shield Promise Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | None | $110.10 |
Browse Plan Formulary |
Blue Shield Promise Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | None | $110.10 |
Browse Plan Formulary |
Blue Shield Vital (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$10.00 | $15.00 | None | $110.40 |
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 |
Blue Shield Vital (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$10.00 | $15.00 | None | $110.40 |
Browse Plan Formulary |
Brand New Day Bridges Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $10.00 | None | $80.40 |
Browse Plan Formulary |
Brand New Day Bridges Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $10.00 | None | $80.40 |
Browse Plan Formulary |
Brand New Day Classic Care I Plan (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $10.00 | None | $80.40 |
Browse Plan Formulary |
Brand New Day Classic Care I Plan (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $10.00 | None | $80.40 |
Browse Plan Formulary |
Brand New Day Classic Care II Plan (HMO)
|
$0.00 |
$50 |
No |
2 |
Generic |
$12.00 | $24.00 | None | $80.40 |
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 |
Brand New Day Classic Care II Plan (HMO)
|
$0.00 |
$50 |
No |
2 |
Generic |
$12.00 | $24.00 | None | $80.40 |
Browse Plan Formulary |
Brand New Day Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$9.00 | $18.00 | None | $80.40 |
Browse Plan Formulary select insulin pay $9-$20 copay but not this drug |
Brand New Day Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$9.00 | $18.00 | None | $80.40 |
Browse Plan Formulary select insulin pay $9-$20 copay but not this drug |
Brand New Day Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$9.00 | $18.00 | None | $80.40 |
Browse Plan Formulary select insulin pay $9-$20 copay but not this drug |
Brand New Day Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$9.00 | $18.00 | None | $80.40 |
Browse Plan Formulary select insulin pay $9-$20 copay but not this drug |
Brand New Day Harmony Care Plan (HMO C-SNP)
|
$0.00 |
$100* |
No |
2* |
Generic |
$10.00 | $20.00 | None | $80.40 |
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 |
Brand New Day Harmony Care Plan (HMO C-SNP)
|
$0.00 |
$100* |
No |
2* |
Generic |
$10.00 | $20.00 | None | $80.40 |
Browse Plan Formulary |
Brand New Day Select Care I Plan (HMO I-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$9.00 | $18.00 | None | $80.40 |
Browse Plan Formulary |
Brand New Day Select Care I Plan (HMO I-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$9.00 | $18.00 | None | $80.40 |
Browse Plan Formulary |
Central Health Focus Plan (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$0.00 | $0.00 | None | $80.40 |
Browse Plan Formulary |
Central Health Focus Plan (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$0.00 | $0.00 | None | $80.40 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$0.00 | $0.00 | None | $80.40 |
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 Medicare Plan (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$0.00 | $0.00 | None | $80.40 |
Browse Plan Formulary |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $10.00 | None | $80.40 |
Browse Plan Formulary select insulin pay $5-$35 copay but not this drug |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $10.00 | None | $80.40 |
Browse Plan Formulary select insulin pay $5-$35 copay but not this drug |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $10.00 | None | $80.40 |
Browse Plan Formulary select insulin pay $5-$35 copay but not this drug |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
1 |
Tier 1 |
0% | 0% | None | $68.40 |
Browse Plan Formulary |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
1 |
Tier 1 |
0% | 0% | None | $68.40 |
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)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $101.10 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $101.10 |
Browse Plan Formulary |
Health Net Jade (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $101.40 |
Browse Plan Formulary |
Health Net Jade (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $101.40 |
Browse Plan Formulary |
Heart & Diabetes (HMO C-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$30.00 | $75.00 | None | $150.00 |
Browse Plan Formulary |
Heart & Diabetes (HMO C-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$30.00 | $75.00 | None | $150.00 |
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 |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $157.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $157.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Imperial Dynamic Plan (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$3.00 | $5.00 | None | $130.50 |
Browse Plan Formulary |
Imperial Dynamic Plan (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$3.00 | $5.00 | None | $130.50 |
Browse Plan Formulary |
Imperial Senior Value (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $10.00 | None | $134.40 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Imperial Senior Value (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $10.00 | None | $134.40 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
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 (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $10.00 | None | $134.40 |
Browse Plan Formulary |
Imperial Traditional (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $10.00 | None | $134.40 |
Browse Plan Formulary |
Inter Valley Health Plan Service To Seniors (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $10.00 | None | $83.40 |
Browse Plan Formulary select insulin pay $11-$35 copay but not this drug |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$10.00 | $20.00 | None | $176.40 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$10.00 | $20.00 | None | $176.40 |
Browse Plan Formulary |
L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
1 |
Tier 1 |
0% | 0% | None | $94.50 |
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 |
L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
1 |
Tier 1 |
0% | 0% | None | $94.50 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
1 |
Tier 1 |
0% | 0% | None | $60.60 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
1 |
Tier 1 |
0% | 0% | None | $60.60 |
Browse Plan Formulary |
My Choice (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$30.00 | $75.00 | None | $150.00 |
Browse Plan Formulary |
My Choice (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$30.00 | $75.00 | None | $150.00 |
Browse Plan Formulary |
PHP (HMO C-SNP)
|
$0.00 |
$445 |
No |
1 |
Generic |
15% | n/a | None | $80.40 |
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 |
PHP (HMO C-SNP)
|
$0.00 |
$445 |
No |
1 |
Generic |
15% | n/a | None | $80.40 |
Browse Plan Formulary |
Platinum (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$30.00 | $75.00 | None | $150.00 |
Browse Plan Formulary |
Platinum (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$30.00 | $75.00 | None | $150.00 |
Browse Plan Formulary |
SCAN Balance (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$2.00 | $0.00 | None | $120.30 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
SCAN Balance (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$2.00 | $0.00 | None | $120.30 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
SCAN Classic (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $0.00 | None | $120.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
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 (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $0.00 | None | $120.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SCAN Healthy at Home (HMO I-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $0.00 | None | $120.60 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO I-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $0.00 | None | $120.60 |
Browse Plan Formulary |
smartHMO (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$30.00 | $75.00 | None | $150.00 |
Browse Plan Formulary |
smartHMO (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$30.00 | $75.00 | None | $150.00 |
Browse Plan Formulary |
WellCare Best (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$0.00 | $0.00 | None | $61.20 |
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 |
Generic |
$0.00 | $0.00 | None | $61.20 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$10.00 | $0.00 | None | $60.30 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$10.00 | $0.00 | None | $60.30 |
Browse Plan Formulary |
WellCare Freedom (HMO D-SNP)
|
$4.20 |
$445 |
No |
4 |
Non-Preferred Drug |
45% | 45% | None | $61.80 |
Browse Plan Formulary |
WellCare Freedom (HMO D-SNP)
|
$4.20 |
$445 |
No |
4 |
Non-Preferred Drug |
45% | 45% | None | $61.80 |
Browse Plan Formulary |
WellCare Plus (HMO)
|
$6.70 |
$445 |
No |
4 |
Non-Preferred Drug |
45% | 45% | None | $61.80 |
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 |
WellCare Plus (HMO)
|
$6.70 |
$445 |
No |
4 |
Non-Preferred Drug |
45% | 45% | None | $61.80 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$12.20 |
$445 |
No |
2 |
Generic |
$15.00 | $45.00 | None | $86.40 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$12.20 |
$445 |
No |
2 |
Generic |
$15.00 | $45.00 | None | $86.40 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$17.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $102.60 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$17.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $102.60 |
Browse Plan Formulary |
AARP Medicare Advantage SecureHorizons Premier (HMO)
|
$19.10 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $90.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
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)
|
$19.10 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $90.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
CalPlus (HMO)
|
$20.10 |
$445 |
No |
3 |
Preferred Brand |
23% | 23% | None | $150.30 |
Browse Plan Formulary |
CalPlus (HMO)
|
$20.10 |
$445 |
No |
3 |
Preferred Brand |
23% | 23% | None | $150.30 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$20.40 |
$445 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $157.20 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$20.40 |
$445 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $157.20 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Assure (HMO)
|
$22.50 |
$445 |
No |
3 |
Tier 3 |
25% | 25% | None | $89.70 |
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 |
UnitedHealthcare Medicare Advantage Assure (HMO)
|
$22.50 |
$445 |
No |
3 |
Tier 3 |
25% | 25% | None | $89.70 |
Browse Plan Formulary |
Anthem MediBlue Connect (HMO D-SNP)
|
$23.30 |
$445* |
No |
2* |
Generic |
$0.00 | $0.00 | None | $138.00 |
Browse Plan Formulary |
Anthem MediBlue Connect (HMO D-SNP)
|
$23.30 |
$445* |
No |
2* |
Generic |
$0.00 | $0.00 | None | $138.00 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$23.50 |
$445 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
25% | 25% | None | $138.00 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$23.50 |
$445 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
25% | 25% | None | $138.00 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$23.50 |
$445 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
25% | 25% | None | $138.00 |
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 Connect Plus (HMO)
|
$23.50 |
$445 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
25% | 25% | None | $138.00 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$23.50 |
$445 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
25% | 25% | None | $138.00 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$23.50 |
$445 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
25% | 25% | None | $138.00 |
Browse Plan Formulary |
SCAN Prime (HMO)
|
$25.00 |
$0 |
No |
2 |
Generic |
$5.00 | $0.00 | None | $120.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SCAN Prime (HMO)
|
$25.00 |
$0 |
No |
2 |
Generic |
$5.00 | $0.00 | None | $120.30 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Health Net Sapphire Premier (HMO)
|
$25.40 |
$445 |
No |
4 |
Non-Preferred Drug |
45% | 45% | None | $66.30 |
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 Sapphire Premier (HMO)
|
$25.40 |
$445 |
No |
4 |
Non-Preferred Drug |
45% | 45% | None | $66.30 |
Browse Plan Formulary |
Health Net Amber II (HMO D-SNP)
|
$26.60 |
$445 |
No |
4 |
Non-Preferred Drug |
46% | 46% | None | $66.90 |
Browse Plan Formulary |
Health Net Amber II (HMO D-SNP)
|
$26.60 |
$445 |
No |
4 |
Non-Preferred Drug |
46% | 46% | None | $66.90 |
Browse Plan Formulary |
Health Net Sapphire Premier II (HMO)
|
$26.70 |
$445 |
No |
4 |
Non-Preferred Drug |
47% | 47% | None | $66.30 |
Browse Plan Formulary |
Health Net Sapphire Premier II (HMO)
|
$26.70 |
$445 |
No |
4 |
Non-Preferred Drug |
47% | 47% | None | $66.30 |
Browse Plan Formulary |
Health Net Amber I (HMO D-SNP)
|
$27.80 |
$445 |
No |
4 |
Non-Preferred Drug |
41% | 41% | None | $66.90 |
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 Amber I (HMO D-SNP)
|
$27.80 |
$445 |
No |
4 |
Non-Preferred Drug |
41% | 41% | None | $66.90 |
Browse Plan Formulary |
Health Net Sapphire (HMO)
|
$28.50 |
$445 |
No |
4 |
Non-Preferred Drug |
46% | 46% | None | $66.60 |
Browse Plan Formulary |
Health Net Sapphire (HMO)
|
$28.50 |
$445 |
No |
4 |
Non-Preferred Drug |
46% | 46% | None | $66.60 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$28.90 |
$0 |
No |
2 |
Tier 2 |
$15.00 | $30.00 | None | $175.80 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$28.90 |
$0 |
No |
2 |
Tier 2 |
$15.00 | $30.00 | None | $175.80 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP)
|
$30.50 |
$445 |
No |
2 |
Tier 2 |
15% | 15% | None | $175.80 |
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)
|
$30.50 |
$445 |
No |
2 |
Tier 2 |
15% | 15% | None | $175.80 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$31.50 |
$445 |
No |
2 |
Generic |
$2.00 | $6.00 | None | $84.00 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$31.50 |
$445 |
No |
2 |
Generic |
$2.00 | $6.00 | None | $84.00 |
Browse Plan Formulary |
Blue Shield Coordinated Choice Plan (HMO)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | None | $109.80 |
Browse Plan Formulary |
Blue Shield Coordinated Choice Plan (HMO)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | None | $109.80 |
Browse Plan Formulary |
Blue Shield TotalDual Plan (HMO D-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | None | $110.40 |
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 |
Blue Shield TotalDual Plan (HMO D-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | None | $110.40 |
Browse Plan Formulary |
Brand New Day Bridges Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $80.40 |
Browse Plan Formulary |
Brand New Day Bridges Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $80.40 |
Browse Plan Formulary |
Brand New Day Classic Choice Plan (HMO)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $80.40 |
Browse Plan Formulary |
Brand New Day Classic Choice Plan (HMO)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $80.40 |
Browse Plan Formulary |
Brand New Day Dual Access Plan (HMO D-SNP)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $80.40 |
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 |
Brand New Day Dual Access Plan (HMO D-SNP)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $80.40 |
Browse Plan Formulary |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $80.40 |
Browse Plan Formulary |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $80.40 |
Browse Plan Formulary |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $80.40 |
Browse Plan Formulary |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $80.40 |
Browse Plan Formulary |
Brand New Day Harmony Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $80.40 |
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 |
Brand New Day Harmony Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $80.40 |
Browse Plan Formulary |
Brand New Day Select Choice I Plan (HMO I-SNP)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $80.40 |
Browse Plan Formulary |
Brand New Day Select Choice I Plan (HMO I-SNP)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $80.40 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO D-SNP)
|
$31.50 |
$445* |
No |
2* |
Generic |
$0.00 | $0.00 | None | $80.40 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO D-SNP)
|
$31.50 |
$445* |
No |
2* |
Generic |
$0.00 | $0.00 | None | $80.40 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$31.50 |
$445* |
No |
2* |
Generic |
$0.00 | $0.00 | None | $80.40 |
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 Premier Plan (HMO)
|
$31.50 |
$445* |
No |
2* |
Generic |
$0.00 | $0.00 | None | $80.40 |
Browse Plan Formulary |
Clever Care Balance Medicare Advantage (HMO)
|
$31.50 |
$435 |
No |
2 |
Generic |
25% | 25% | None | $80.40 |
Browse Plan Formulary |
Clever Care Balance Medicare Advantage (HMO)
|
$31.50 |
$435 |
No |
2 |
Generic |
25% | 25% | None | $80.40 |
Browse Plan Formulary |
Clever Care Balance Medicare Advantage (HMO)
|
$31.50 |
$435 |
No |
2 |
Generic |
25% | 25% | None | $80.40 |
Browse Plan Formulary |
Imperial Traditional Plus (HMO)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $134.40 |
Browse Plan Formulary |
Imperial Traditional Plus (HMO)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $134.40 |
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 |
Inter Valley Health Plan Vitality Plus (HMO)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $83.40 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
29% | 29% | None | $67.50 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
29% | 29% | None | $67.50 |
Browse Plan Formulary |
SCAN Connections (HMO D-SNP)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $120.30 |
Browse Plan Formulary |
SCAN Connections (HMO D-SNP)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $120.30 |
Browse Plan Formulary |
SCAN Connections at Home (HMO D-SNP)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $120.30 |
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)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $120.30 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $120.60 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $120.60 |
Browse Plan Formulary |
VillageHealth (HMO-POS C-SNP)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $120.30 |
Browse Plan Formulary |
VillageHealth (HMO-POS C-SNP)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $120.30 |
Browse Plan Formulary |
SCAN Classic II (HMO)
|
$59.00 |
$0 |
No |
2 |
Generic |
$7.00 | $0.00 | None | $120.30 |
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)
|
$59.00 |
$0 |
No |
2 |
Generic |
$7.00 | $0.00 | None | $120.30 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$89.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $96.90 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$89.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $96.90 |
Browse Plan Formulary |