AMITIZA 24 MCG 60 CAPSULE BOTTLE (60 CAP BOT) (NDC: 64764024060)
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. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $395.40 |
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 | Q:60 /30Days | $395.40 |
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 | Q:60 /30Days | $395.40 |
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 | Q:60 /30Days | $395.40 |
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 | Q:60 /30Days | $395.40 |
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 | Q:60 /30Days | $395.40 |
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 | Q:60 /30Days | $395.40 |
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 | Q:60 /30Days | $395.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Anthem Blue Cross Cal MediConnect (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | Q:60 /30Days | $361.20 |
Browse Plan Formulary |
Anthem Blue Cross Cal MediConnect (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | Q:60 /30Days | $361.20 |
Browse Plan Formulary |
Anthem MediBlue Care On Site (HMO I-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$37.50 | $75.00 | Q:60 /30Days | $361.20 |
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 |
Anthem MediBlue Care On Site (HMO I-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$37.50 | $75.00 | Q:60 /30Days | $361.20 |
Browse Plan Formulary |
Anthem MediBlue Diabetes Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$37.50 | $75.00 | Q:60 /30Days | $361.20 |
Browse Plan Formulary |
Anthem MediBlue Diabetes Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$37.50 | $75.00 | Q:60 /30Days | $361.20 |
Browse Plan Formulary |
Anthem MediBlue ESRD Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$37.50 | $75.00 | Q:60 /30Days | $361.20 |
Browse Plan Formulary |
Anthem MediBlue ESRD Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$37.50 | $75.00 | Q:60 /30Days | $361.20 |
Browse Plan Formulary |
Anthem MediBlue Heart Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$37.50 | $75.00 | Q:60 /30Days | $361.20 |
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 |
Anthem MediBlue Heart Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$37.50 | $75.00 | Q:60 /30Days | $361.20 |
Browse Plan Formulary |
Anthem MediBlue Lung Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$37.50 | $75.00 | Q:60 /30Days | $361.20 |
Browse Plan Formulary |
Anthem MediBlue Lung Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$37.50 | $75.00 | Q:60 /30Days | $361.20 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:60 /30Days | $389.40 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:60 /30Days | $389.40 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:60 /30Days | $390.00 |
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 Select (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:60 /30Days | $390.00 |
Browse Plan Formulary |
Anthem MediBlue StartSmart Plus (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days | $361.20 |
Browse Plan Formulary |
Anthem MediBlue StartSmart Plus (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days | $361.20 |
Browse Plan Formulary |
Anthem MediBlue Value Plus (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$37.50 | $75.00 | Q:60 /30Days | $361.20 |
Browse Plan Formulary |
Anthem MediBlue Value Plus (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$37.50 | $75.00 | Q:60 /30Days | $361.20 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $95.00 | Q:2 /1Days | $359.40 |
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 65 Plus (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$38.00 | $95.00 | Q:2 /1Days | $359.40 |
Browse Plan Formulary |
Blue Shield 65 Plus Plan 2 (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:2 /1Days | $359.40 |
Browse Plan Formulary |
Blue Shield 65 Plus Plan 2 (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:2 /1Days | $359.40 |
Browse Plan Formulary |
Blue Shield AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:2 /1Days | $359.40 |
Browse Plan Formulary |
Blue Shield AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:2 /1Days | $359.40 |
Browse Plan Formulary |
Blue Shield Inspire (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$35.00 | $87.50 | Q:2 /1Days | $359.40 |
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 Inspire (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$35.00 | $87.50 | Q:2 /1Days | $359.40 |
Browse Plan Formulary |
Blue Shield Promise Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
3 |
Tier 3 |
0% | 0% | Q:2 /1Days | $361.20 |
Browse Plan Formulary |
Blue Shield Promise Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
3 |
Tier 3 |
0% | 0% | Q:2 /1Days | $361.20 |
Browse Plan Formulary |
Blue Shield Vital (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:2 /1Days | $359.40 |
Browse Plan Formulary |
Blue Shield Vital (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:2 /1Days | $359.40 |
Browse Plan Formulary |
Brand New Day Bridges Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days | $363.60 |
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 |
Brand New Day Bridges Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days | $363.60 |
Browse Plan Formulary |
Brand New Day Classic Care I Plan (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:60 /30Days | $363.60 |
Browse Plan Formulary |
Brand New Day Classic Care I Plan (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:60 /30Days | $363.60 |
Browse Plan Formulary |
Brand New Day Classic Care II Plan (HMO)
|
$0.00 |
$50 |
No |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:60 /30Days | $363.60 |
Browse Plan Formulary |
Brand New Day Classic Care II Plan (HMO)
|
$0.00 |
$50 |
No |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:60 /30Days | $363.60 |
Browse Plan Formulary |
Brand New Day Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:60 /30Days | $363.60 |
Browse Plan Formulary select insulin pay $9-$20 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 |
Brand New Day Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:60 /30Days | $363.60 |
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 |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:60 /30Days | $363.60 |
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 |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:60 /30Days | $363.60 |
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 |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days | $363.60 |
Browse Plan Formulary |
Brand New Day Harmony Care Plan (HMO C-SNP)
|
$0.00 |
$100 |
No |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days | $363.60 |
Browse Plan Formulary |
Brand New Day Select Care I Plan (HMO I-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:60 /30Days | $363.60 |
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 |
Brand New Day Select Care I Plan (HMO I-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$47.00 | $94.00 | Q:60 /30Days | $363.60 |
Browse Plan Formulary |
Central Health Focus Plan (HMO C-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:60 /30Days | $360.00 |
Browse Plan Formulary |
Central Health Focus Plan (HMO C-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:60 /30Days | $360.00 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:60 /30Days | $360.00 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:60 /30Days | $360.00 |
Browse Plan Formulary |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:60 /30Days | $360.00 |
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 |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:60 /30Days | $360.00 |
Browse Plan Formulary select insulin pay $5-$35 copay but not this drug |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$35.00 | $70.00 | Q:60 /30Days | $360.00 |
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. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:60 /30Days | $391.20 |
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 | Q:60 /30Days | $391.20 |
Browse Plan Formulary |
Health Net Jade (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:60 /30Days | $391.20 |
Browse Plan Formulary |
Health Net Jade (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:60 /30Days | $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 |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None | $399.60 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Brand |
$100.00 | $200.00 | None | $399.60 |
Browse Plan Formulary |
PHP (HMO C-SNP)
|
$0.00 |
$445 |
No |
2 |
Preferred Brand |
15% | n/a | Q:60 /30Days | $360.00 |
Browse Plan Formulary |
PHP (HMO C-SNP)
|
$0.00 |
$445 |
No |
2 |
Preferred Brand |
15% | n/a | Q:60 /30Days | $360.00 |
Browse Plan Formulary |
SCAN Balance (HMO C-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$30.00 | $70.00 | None | $360.60 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
SCAN Balance (HMO C-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$30.00 | $70.00 | None | $360.60 |
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 |
3 |
Preferred Brand |
$37.00 | $91.00 | None | $360.60 |
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 | $360.60 |
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 | $360.60 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO I-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $360.60 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$12.20 |
$445 |
No |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days | $389.40 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$12.20 |
$445 |
No |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days | $389.40 |
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 Healthy Heart (HMO)
|
$17.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | Q:60 /30Days | $391.20 |
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 | Q:60 /30Days | $391.20 |
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 | Q:60 /30Days | $395.40 |
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. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:60 /30Days | $395.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Medicare Advantage Assure (HMO)
|
$22.50 |
$445 |
No |
3 |
Tier 3 |
25% | 25% | Q:60 /30Days | $395.40 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Assure (HMO)
|
$22.50 |
$445 |
No |
3 |
Tier 3 |
25% | 25% | Q:60 /30Days | $395.40 |
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 Connect (HMO D-SNP)
|
$23.30 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $361.20 |
Browse Plan Formulary |
Anthem MediBlue Connect (HMO D-SNP)
|
$23.30 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $361.20 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$23.50 |
$445 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $361.20 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$23.50 |
$445 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $361.20 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$23.50 |
$445 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $361.20 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$23.50 |
$445 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $361.20 |
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 |
Anthem MediBlue Connect Plus (HMO)
|
$23.50 |
$445 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $361.20 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$23.50 |
$445 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $361.20 |
Browse Plan Formulary |
SCAN Prime (HMO)
|
$25.00 |
$0 |
No |
3 |
Preferred Brand |
$37.00 | $91.00 | None | $360.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SCAN Prime (HMO)
|
$25.00 |
$0 |
No |
3 |
Preferred Brand |
$37.00 | $91.00 | None | $360.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Health Net Sapphire (HMO)
|
$28.50 |
$445 |
No |
4 |
Non-Preferred Drug |
46% | 46% | Q:60 /30Days | n/a |
Browse Plan Formulary |
Health Net Sapphire (HMO)
|
$28.50 |
$445 |
No |
4 |
Non-Preferred Drug |
46% | 46% | Q:60 /30Days | n/a |
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 |
4 |
Tier 4 |
$100.00 | $200.00 | None | $391.20 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$28.90 |
$0 |
No |
4 |
Tier 4 |
$100.00 | $200.00 | None | $391.20 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP)
|
$30.50 |
$445 |
No |
4 |
Tier 4 |
15% | 15% | None | $391.20 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP)
|
$30.50 |
$445 |
No |
4 |
Tier 4 |
15% | 15% | None | $391.20 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days | $389.40 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:60 /30Days | $389.40 |
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 Coordinated Choice Plan (HMO)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | Q:2 /1Days | $361.20 |
Browse Plan Formulary |
Blue Shield Coordinated Choice Plan (HMO)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | Q:2 /1Days | $361.20 |
Browse Plan Formulary |
Blue Shield TotalDual Plan (HMO D-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | Q:2 /1Days | $361.20 |
Browse Plan Formulary |
Blue Shield TotalDual Plan (HMO D-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | Q:2 /1Days | $361.20 |
Browse Plan Formulary |
Brand New Day Bridges Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $363.60 |
Browse Plan Formulary |
Brand New Day Bridges Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $363.60 |
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 |
Brand New Day Classic Choice Plan (HMO)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $363.60 |
Browse Plan Formulary |
Brand New Day Classic Choice Plan (HMO)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $363.60 |
Browse Plan Formulary |
Brand New Day Dual Access Plan (HMO D-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $363.60 |
Browse Plan Formulary |
Brand New Day Dual Access Plan (HMO D-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $363.60 |
Browse Plan Formulary |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $363.60 |
Browse Plan Formulary |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $363.60 |
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 |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $363.60 |
Browse Plan Formulary |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $363.60 |
Browse Plan Formulary |
Brand New Day Harmony Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $363.60 |
Browse Plan Formulary |
Brand New Day Harmony Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $363.60 |
Browse Plan Formulary |
Brand New Day Select Choice I Plan (HMO I-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $363.60 |
Browse Plan Formulary |
Brand New Day Select Choice I Plan (HMO I-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $363.60 |
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 |
Central Health Medi-Medi Plan (HMO D-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $360.00 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO D-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $360.00 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $360.00 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $360.00 |
Browse Plan Formulary |
Clever Care Balance Medicare Advantage (HMO)
|
$31.50 |
$435 |
No |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $360.00 |
Browse Plan Formulary |
Clever Care Balance Medicare Advantage (HMO)
|
$31.50 |
$435 |
No |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $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 |
Clever Care Balance Medicare Advantage (HMO)
|
$31.50 |
$435 |
No |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $360.00 |
Browse Plan Formulary |
SCAN Connections (HMO D-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | None | $360.60 |
Browse Plan Formulary |
SCAN Connections (HMO D-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | None | $360.60 |
Browse Plan Formulary |
SCAN Connections at Home (HMO D-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | None | $360.60 |
Browse Plan Formulary |
SCAN Connections at Home (HMO D-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | None | $360.60 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | None | $360.60 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SCAN Plus (HMO)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | None | $360.60 |
Browse Plan Formulary |
VillageHealth (HMO-POS C-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | None | $360.60 |
Browse Plan Formulary |
VillageHealth (HMO-POS C-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | None | $360.60 |
Browse Plan Formulary |
SCAN Classic II (HMO)
|
$59.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $106.00 | None | $360.60 |
Browse Plan Formulary |
SCAN Classic II (HMO)
|
$59.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $106.00 | None | $360.60 |
Browse Plan Formulary |