ALBUTEROL SULFATE 2 MG TABLET (100.000 EA ) (NDC: 00378025501)
2021 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
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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 | None | $178.80 |
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. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $178.80 |
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 | None | $178.80 |
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 | None | $178.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $178.80 |
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 |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $178.80 |
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 | None | $178.80 |
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 | None | $178.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Plus Plan (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$37.00 | $111.00 | None | $132.00 |
Browse Plan Formulary |
Aetna Medicare Plus Plan (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$37.00 | $111.00 | None | $132.00 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $129.60 |
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 Prime Plan (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $129.60 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $132.00 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $132.00 |
Browse Plan Formulary |
Anthem Blue Cross Cal MediConnect (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
1 |
Tier 1 |
0% | 0% | None | $108.00 |
Browse Plan Formulary |
Anthem Blue Cross Cal MediConnect (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
1 |
Tier 1 |
0% | 0% | None | $108.00 |
Browse Plan Formulary |
Anthem MediBlue Care On Site (HMO I-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$9.50 | $19.00 | None | $429.60 |
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)
|
$0.00 |
$0 |
No |
2 |
Generic |
$9.50 | $19.00 | None | $429.60 |
Browse Plan Formulary |
Anthem MediBlue Diabetes Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$7.50 | $15.00 | None | $429.60 |
Browse Plan Formulary |
Anthem MediBlue Diabetes Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$7.50 | $15.00 | None | $429.60 |
Browse Plan Formulary |
Anthem MediBlue ESRD Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$7.50 | $15.00 | None | $429.60 |
Browse Plan Formulary |
Anthem MediBlue ESRD Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$7.50 | $15.00 | None | $429.60 |
Browse Plan Formulary |
Anthem MediBlue Heart Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$7.50 | $15.00 | None | $429.60 |
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 Heart Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$7.50 | $15.00 | None | $429.60 |
Browse Plan Formulary |
Anthem MediBlue Lung Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$7.50 | $15.00 | None | $429.60 |
Browse Plan Formulary |
Anthem MediBlue Lung Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$7.50 | $15.00 | None | $429.60 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $225.60 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $225.60 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $224.40 |
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 |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $224.40 |
Browse Plan Formulary |
Anthem MediBlue StartSmart Plus (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$14.50 | $29.00 | None | $429.60 |
Browse Plan Formulary |
Anthem MediBlue StartSmart Plus (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$14.50 | $29.00 | None | $429.60 |
Browse Plan Formulary |
Anthem MediBlue Value Plus (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$9.50 | $19.00 | None | $429.60 |
Browse Plan Formulary |
Anthem MediBlue Value Plus (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$9.50 | $19.00 | None | $429.60 |
Browse Plan Formulary |
AVA (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | None | $328.80 |
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 |
AVA (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | None | $328.80 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | None | $360.00 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | None | $360.00 |
Browse Plan Formulary |
Blue Shield 65 Plus Plan 2 (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | None | $362.40 |
Browse Plan Formulary |
Blue Shield 65 Plus Plan 2 (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | None | $362.40 |
Browse Plan Formulary |
Blue Shield AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | None | $360.00 |
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 |
Blue Shield AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | None | $360.00 |
Browse Plan Formulary |
Blue Shield Inspire (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | None | $360.00 |
Browse Plan Formulary |
Blue Shield Inspire (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | None | $360.00 |
Browse Plan Formulary |
Blue Shield Promise Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | None | $358.80 |
Browse Plan Formulary |
Blue Shield Promise Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | None | $358.80 |
Browse Plan Formulary |
Blue Shield Vital (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | None | $360.00 |
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 |
Blue Shield Vital (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | None | $360.00 |
Browse Plan Formulary |
Central Health Focus Plan (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$0.00 | $0.00 | None | $202.80 |
Browse Plan Formulary |
Central Health Focus Plan (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$0.00 | $0.00 | None | $202.80 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$0.00 | $0.00 | None | $202.80 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$0.00 | $0.00 | None | $202.80 |
Browse Plan Formulary |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $10.00 | None | $202.80 |
Browse Plan Formulary select insulin pay $5-$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 |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $10.00 | None | $202.80 |
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 | $202.80 |
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 | $337.20 |
Browse Plan Formulary |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
1 |
Tier 1 |
0% | 0% | None | $337.20 |
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 | $370.80 |
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 | $370.80 |
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 Jade (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $370.80 |
Browse Plan Formulary |
Health Net Jade (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $370.80 |
Browse Plan Formulary |
Heart & Diabetes (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$75.00 | $187.50 | None | $315.60 |
Browse Plan Formulary |
Heart & Diabetes (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$75.00 | $187.50 | None | $315.60 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:120 /30Days | $507.60 |
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 | Q:120 /30Days | $507.60 |
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 |
Imperial Dynamic Plan (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$3.00 | $5.00 | None | $308.40 |
Browse Plan Formulary |
Imperial Dynamic Plan (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$3.00 | $5.00 | None | $308.40 |
Browse Plan Formulary |
Imperial Senior Value (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $10.00 | None | $309.60 |
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 | $309.60 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Imperial Traditional (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $10.00 | None | $309.60 |
Browse Plan Formulary |
Imperial Traditional (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $10.00 | None | $309.60 |
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 |
Inter Valley Health Plan Service To Seniors (HMO)
|
$0.00 |
$0 |
No |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $127.20 |
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 | $178.80 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$10.00 | $20.00 | None | $178.80 |
Browse Plan Formulary |
L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
1 |
Tier 1 |
0% | 0% | None | $106.80 |
Browse Plan Formulary |
L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
1 |
Tier 1 |
0% | 0% | None | $106.80 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
1 |
Tier 1 |
0% | 0% | None | $417.60 |
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 |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
1 |
Tier 1 |
0% | 0% | None | $417.60 |
Browse Plan Formulary |
My Choice (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $333.60 |
Browse Plan Formulary |
My Choice (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $333.60 |
Browse Plan Formulary |
Platinum (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$75.00 | $187.50 | None | $315.60 |
Browse Plan Formulary |
Platinum (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$75.00 | $187.50 | None | $315.60 |
Browse Plan Formulary |
SCAN Balance (HMO C-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$30.00 | $70.00 | None | $391.20 |
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 Balance (HMO C-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$30.00 | $70.00 | None | $391.20 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
SCAN Classic (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$37.00 | $91.00 | None | $387.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SCAN Classic (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$37.00 | $91.00 | None | $387.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SCAN Healthy at Home (HMO I-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $393.60 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO I-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $393.60 |
Browse Plan Formulary |
smartHMO (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $301.20 |
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 |
smartHMO (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $301.20 |
Browse Plan Formulary |
WellCare Best (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$0.00 | $0.00 | None | $198.00 |
Browse Plan Formulary |
WellCare Best (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$0.00 | $0.00 | None | $198.00 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$10.00 | $0.00 | None | $200.40 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$10.00 | $0.00 | None | $200.40 |
Browse Plan Formulary |
WellCare Freedom (HMO D-SNP)
|
$4.20 |
$445 |
No |
4 |
Non-Preferred Drug |
45% | 45% | None | $200.40 |
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 |
WellCare Freedom (HMO D-SNP)
|
$4.20 |
$445 |
No |
4 |
Non-Preferred Drug |
45% | 45% | None | $200.40 |
Browse Plan Formulary |
WellCare Plus (HMO)
|
$6.70 |
$445 |
No |
4 |
Non-Preferred Drug |
45% | 45% | None | $200.40 |
Browse Plan Formulary |
WellCare Plus (HMO)
|
$6.70 |
$445 |
No |
4 |
Non-Preferred Drug |
45% | 45% | None | $200.40 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$12.20 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $225.60 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$12.20 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $225.60 |
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 | $373.20 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Health Net Healthy Heart (HMO)
|
$17.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $373.20 |
Browse Plan Formulary |
AARP Medicare Advantage SecureHorizons Premier (HMO)
|
$19.10 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $178.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage SecureHorizons Premier (HMO)
|
$19.10 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $178.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
CalPlus (HMO)
|
$20.10 |
$445 |
No |
4 |
Non-Preferred Drug |
23% | 23% | None | $396.00 |
Browse Plan Formulary |
CalPlus (HMO)
|
$20.10 |
$445 |
No |
4 |
Non-Preferred Drug |
23% | 23% | None | $396.00 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$20.40 |
$445 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:120 /30Days | $506.40 |
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 |
Humana Value Plus H5619-037 (HMO)
|
$20.40 |
$445 |
No |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:120 /30Days | $506.40 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Assure (HMO)
|
$22.50 |
$445 |
No |
4 |
Tier 4 |
25% | 25% | None | $180.00 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Assure (HMO)
|
$22.50 |
$445 |
No |
4 |
Tier 4 |
25% | 25% | None | $180.00 |
Browse Plan Formulary |
Anthem MediBlue Connect (HMO D-SNP)
|
$23.30 |
$445* |
No |
2* |
Generic |
$0.00 | $0.00 | None | $429.60 |
Browse Plan Formulary |
Anthem MediBlue Connect (HMO D-SNP)
|
$23.30 |
$445* |
No |
2* |
Generic |
$0.00 | $0.00 | None | $429.60 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$23.50 |
$445 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
25% | 25% | None | $429.60 |
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 Connect Plus (HMO)
|
$23.50 |
$445 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
25% | 25% | None | $429.60 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$23.50 |
$445 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
25% | 25% | None | $429.60 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$23.50 |
$445 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
25% | 25% | None | $429.60 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$23.50 |
$445 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
25% | 25% | None | $429.60 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$23.50 |
$445 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
25% | 25% | None | $429.60 |
Browse Plan Formulary |
SCAN Prime (HMO)
|
$25.00 |
$0 |
No |
3 |
Preferred Brand |
$37.00 | $91.00 | None | $387.60 |
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 Prime (HMO)
|
$25.00 |
$0 |
No |
3 |
Preferred Brand |
$37.00 | $91.00 | None | $387.60 |
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 | $309.60 |
Browse Plan Formulary |
Health Net Sapphire Premier (HMO)
|
$25.40 |
$445 |
No |
4 |
Non-Preferred Drug |
45% | 45% | None | $309.60 |
Browse Plan Formulary |
Health Net Amber II (HMO D-SNP)
|
$26.60 |
$445 |
No |
4 |
Non-Preferred Drug |
46% | 46% | None | $318.00 |
Browse Plan Formulary |
Health Net Amber II (HMO D-SNP)
|
$26.60 |
$445 |
No |
4 |
Non-Preferred Drug |
46% | 46% | None | $318.00 |
Browse Plan Formulary |
Health Net Sapphire Premier II (HMO)
|
$26.70 |
$445 |
No |
4 |
Non-Preferred Drug |
47% | 47% | None | $309.60 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Health Net Sapphire Premier II (HMO)
|
$26.70 |
$445 |
No |
4 |
Non-Preferred Drug |
47% | 47% | None | $309.60 |
Browse Plan Formulary |
Health Net Amber I (HMO D-SNP)
|
$27.80 |
$445 |
No |
4 |
Non-Preferred Drug |
41% | 41% | None | $318.00 |
Browse Plan Formulary |
Health Net Amber I (HMO D-SNP)
|
$27.80 |
$445 |
No |
4 |
Non-Preferred Drug |
41% | 41% | None | $318.00 |
Browse Plan Formulary |
Health Net Sapphire (HMO)
|
$28.50 |
$445 |
No |
4 |
Non-Preferred Drug |
46% | 46% | None | $315.60 |
Browse Plan Formulary |
Health Net Sapphire (HMO)
|
$28.50 |
$445 |
No |
4 |
Non-Preferred Drug |
46% | 46% | None | $315.60 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$28.90 |
$0 |
No |
2 |
Tier 2 |
$15.00 | $30.00 | None | $207.60 |
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)
|
$28.90 |
$0 |
No |
2 |
Tier 2 |
$15.00 | $30.00 | None | $207.60 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP)
|
$30.50 |
$445 |
No |
2 |
Tier 2 |
15% | 15% | None | $207.60 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP)
|
$30.50 |
$445 |
No |
2 |
Tier 2 |
15% | 15% | None | $207.60 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $231.60 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $231.60 |
Browse Plan Formulary |
Blue Shield Coordinated Choice Plan (HMO)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | None | $364.80 |
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 Coordinated Choice Plan (HMO)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | None | $364.80 |
Browse Plan Formulary |
Blue Shield TotalDual Plan (HMO D-SNP)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | None | $362.40 |
Browse Plan Formulary |
Blue Shield TotalDual Plan (HMO D-SNP)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | None | $362.40 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO D-SNP)
|
$31.50 |
$445* |
No |
2* |
Generic |
$0.00 | $0.00 | None | $202.80 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO D-SNP)
|
$31.50 |
$445* |
No |
2* |
Generic |
$0.00 | $0.00 | None | $202.80 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$31.50 |
$445* |
No |
2* |
Generic |
$0.00 | $0.00 | None | $202.80 |
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 |
Central Health Premier Plan (HMO)
|
$31.50 |
$445* |
No |
2* |
Generic |
$0.00 | $0.00 | None | $202.80 |
Browse Plan Formulary |
Clever Care Balance Medicare Advantage (HMO)
|
$31.50 |
$435 |
No |
2 |
Generic |
25% | 25% | None | $202.80 |
Browse Plan Formulary |
Clever Care Balance Medicare Advantage (HMO)
|
$31.50 |
$435 |
No |
2 |
Generic |
25% | 25% | None | $202.80 |
Browse Plan Formulary |
Clever Care Balance Medicare Advantage (HMO)
|
$31.50 |
$435 |
No |
2 |
Generic |
25% | 25% | None | $202.80 |
Browse Plan Formulary |
Imperial Traditional Plus (HMO)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $309.60 |
Browse Plan Formulary |
Imperial Traditional Plus (HMO)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $309.60 |
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 |
Inter Valley Health Plan Vitality Plus (HMO)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $127.20 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
29% | 29% | None | $465.60 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
29% | 29% | None | $465.60 |
Browse Plan Formulary |
SCAN Connections (HMO D-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | None | $391.20 |
Browse Plan Formulary |
SCAN Connections (HMO D-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | None | $391.20 |
Browse Plan Formulary |
SCAN Connections at Home (HMO D-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | None | $391.20 |
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 |
SCAN Connections at Home (HMO D-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | None | $391.20 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | None | $390.00 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | None | $390.00 |
Browse Plan Formulary |
VillageHealth (HMO-POS C-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | None | $387.60 |
Browse Plan Formulary |
VillageHealth (HMO-POS C-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | None | $387.60 |
Browse Plan Formulary |
SCAN Classic II (HMO)
|
$59.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $106.00 | None | $387.60 |
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 Classic II (HMO)
|
$59.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $106.00 | None | $387.60 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$89.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $135.60 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$89.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $135.60 |
Browse Plan Formulary |