FENTANYL CITRATE OTFC 200 MCG LOZENGE HD [Actiq] (30 units ) (NDC: 00093786565)
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. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:120 /30Days | $197.70 |
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. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:120 /30Days | $197.70 |
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. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:120 /30Days | $197.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Plus Plan (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $180.30 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $180.60 |
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 |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $180.30 |
Browse Plan Formulary |
Anthem MediBlue Care On Site (HMO I-SNP)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $126.00 |
Browse Plan Formulary |
Anthem MediBlue Diabetes Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $126.00 |
Browse Plan Formulary |
Anthem MediBlue ESRD Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $126.00 |
Browse Plan Formulary |
Anthem MediBlue Heart Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $126.00 |
Browse Plan Formulary |
Anthem MediBlue Lung Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $126.00 |
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 |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $114.75 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $113.25 |
Browse Plan Formulary |
Anthem MediBlue StartSmart Plus (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $126.00 |
Browse Plan Formulary |
Anthem MediBlue Value Plus (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $126.00 |
Browse Plan Formulary |
Astiva Health Advantage (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | P Q:180 /30Days | $141.00 |
Browse Plan Formulary |
AVA (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $190.35 |
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)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $211.65 |
Browse Plan Formulary |
Blue Shield 65 Plus Plan 2 (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $211.80 |
Browse Plan Formulary |
Blue Shield AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $211.65 |
Browse Plan Formulary |
Blue Shield Inspire (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $211.65 |
Browse Plan Formulary |
Blue Shield Vital (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $211.65 |
Browse Plan Formulary |
Brand New Day Bridges Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $123.75 |
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 I Plan (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $123.75 |
Browse Plan Formulary |
Brand New Day Classic Care II Plan (HMO)
|
$0.00 |
$50 |
No |
5 |
Specialty Tier |
30% | n/a | P Q:120 /30Days | $123.75 |
Browse Plan Formulary |
Brand New Day Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $123.75 |
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 |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $123.75 |
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 |
5 |
Specialty Tier |
30% | n/a | P Q:120 /30Days | $123.75 |
Browse Plan Formulary |
Brand New Day Select Care I Plan (HMO I-SNP)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $123.75 |
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 Focus Plan (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $123.75 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $123.75 |
Browse Plan Formulary |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | 33% | P Q:120 /30Days | $133.65 |
Browse Plan Formulary select insulin pay $5-$35 copay but not this drug |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | 33% | P Q:120 /30Days | $123.75 |
Browse Plan Formulary select insulin pay $5-$35 copay but not this drug |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | 33% | P Q:120 /30Days | $123.75 |
Browse Plan Formulary select insulin pay $5-$35 copay but not this drug |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $127.95 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Health Net Jade (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $127.95 |
Browse Plan Formulary |
Heart & Diabetes (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $190.35 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $164.55 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Imperial Dynamic Plan (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$75.00 | $180.00 | P Q:180 /30Days | $152.70 |
Browse Plan Formulary |
Imperial Senior Value (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | P Q:180 /30Days | $153.15 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Imperial Traditional (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | P Q:180 /30Days | $153.15 |
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 Service To Seniors (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $185.85 |
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 |
5 |
Specialty Tier |
33% | 33% | P | $193.35 |
Browse Plan Formulary |
My Choice (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $188.85 |
Browse Plan Formulary |
OneCare Connect (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
1 |
Tier 1 |
0% | n/a | P Q:180 /30Days | $123.75 |
Browse Plan Formulary |
Platinum (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $190.35 |
Browse Plan Formulary |
SCAN Balance (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P | $137.10 |
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 |
SCAN Classic (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P | $137.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SCAN Healthy at Home (HMO I-SNP)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P | $137.10 |
Browse Plan Formulary |
SCAN Heart First (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P | $137.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
WellCare Best (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $126.45 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $127.05 |
Browse Plan Formulary |
WellCare Plus (HMO)
|
$4.60 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $126.30 |
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 |
Anthem MediBlue Coordination Plus (HMO)
|
$12.20 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $114.75 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$17.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $130.20 |
Browse Plan Formulary |
CalPlus (HMO)
|
$20.10 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $176.25 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$20.40 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $164.40 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Assure (HMO)
|
$22.50 |
$445 |
No |
4 |
Tier 4 |
25% | 25% | P Q:120 /30Days | $196.95 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$23.50 |
$445 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $129.45 |
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. |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $129.45 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$23.50 |
$445 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $126.00 |
Browse Plan Formulary |
Health Net Sapphire Premier (HMO)
|
$25.40 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $148.65 |
Browse Plan Formulary |
SCAN Prime (HMO)
|
$26.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P | $137.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Health Net Amber II (HMO D-SNP)
|
$26.60 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $152.25 |
Browse Plan Formulary |
Health Net Sapphire Premier II (HMO)
|
$26.70 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $148.65 |
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 |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $152.25 |
Browse Plan Formulary |
AARP Medicare Advantage SecureHorizons Premier (HMO)
|
$28.20 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:120 /30Days | $197.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Health Net Sapphire (HMO)
|
$28.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $152.70 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$28.90 |
$0 |
No |
5 |
Tier 5 |
33% | 33% | P | $193.35 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP)
|
$30.50 |
$445 |
No |
5 |
Tier 5 |
15% | 15% | P | $193.35 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$31.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $117.00 |
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 |
Astiva Health Value (HMO)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | P Q:180 /30Days | $141.00 |
Browse Plan Formulary |
Blue Shield Coordinated Choice Plan (HMO)
|
$31.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $211.65 |
Browse Plan Formulary |
Blue Shield TotalDual Plan (HMO D-SNP)
|
$31.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $211.65 |
Browse Plan Formulary |
Brand New Day Bridges Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $123.75 |
Browse Plan Formulary |
Brand New Day Classic Choice Plan (HMO)
|
$31.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $123.75 |
Browse Plan Formulary |
Brand New Day Dual Access Plan (HMO D-SNP)
|
$31.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $123.75 |
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 Embrace Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $123.75 |
Browse Plan Formulary |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $123.75 |
Browse Plan Formulary |
Brand New Day Harmony Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $123.75 |
Browse Plan Formulary |
Brand New Day Select Choice I Plan (HMO I-SNP)
|
$31.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $123.75 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$31.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $123.75 |
Browse Plan Formulary |
Clever Care Balance Medicare Advantage (HMO)
|
$31.50 |
$435 |
No |
5 |
Specialty Tier |
25% | 25% | P Q:120 /30Days | $133.65 |
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 |
Clever Care Balance Medicare Advantage (HMO)
|
$31.50 |
$435 |
No |
5 |
Specialty Tier |
25% | 25% | P Q:120 /30Days | $123.75 |
Browse Plan Formulary |
Clever Care Balance Medicare Advantage (HMO)
|
$31.50 |
$435 |
No |
5 |
Specialty Tier |
25% | 25% | P Q:120 /30Days | $123.75 |
Browse Plan Formulary |
Imperial Traditional Plus (HMO)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | P Q:180 /30Days | $153.15 |
Browse Plan Formulary |
Inter Valley Health Plan Vitality Plus (HMO)
|
$31.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:120 /30Days | $185.85 |
Browse Plan Formulary |
OneCare (HMO D-SNP)
|
$31.50 |
$0 |
No |
1 |
Generic |
$0.00 | n/a | P Q:180 /30Days | $123.75 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$31.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | P | $137.10 |
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 |
Aetna Medicare Choice Plan (PPO)
|
$89.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:120 /30Days | $124.20 |
Browse Plan Formulary |
Anthem MediBlue Access (PPO)
|
$172.00 |
$370 |
No |
5 |
Specialty Tier |
26% | n/a | P Q:120 /30Days | $113.25 |
Browse Plan Formulary |