ARIPIPRAZOLE 1 MG/ML SOLUTION [Abilify] (30 mls ) (NDC: 65162089374)
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 | Q:750 /30Days | $325.50 |
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 | Q:750 /30Days | $325.50 |
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 | Q:750 /30Days | $325.50 |
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 | Q:750 /30Days | $325.50 |
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 | Q:750 /30Days | $325.50 |
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 | Q:750 /30Days | $325.50 |
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 | Q:750 /30Days | $325.50 |
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 | Q:750 /30Days | $325.50 |
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 | Q:900 /30Days | $159.00 |
Browse Plan Formulary |
Aetna Medicare Plus Plan (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$99.00 | $297.00 | Q:900 /30Days | $159.00 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:900 /30Days | $157.50 |
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 | Q:900 /30Days | $157.50 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:900 /30Days | $159.00 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:900 /30Days | $159.00 |
Browse Plan Formulary |
Anthem Blue Cross Cal MediConnect (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
1 |
Tier 1 |
0% | 0% | Q:900 /30Days | $211.50 |
Browse Plan Formulary |
Anthem Blue Cross Cal MediConnect (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
1 |
Tier 1 |
0% | 0% | Q:900 /30Days | $211.50 |
Browse Plan Formulary |
Anthem MediBlue Care On Site (HMO I-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:900 /30Days | $487.50 |
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 |
Anthem MediBlue Care On Site (HMO I-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:900 /30Days | $487.50 |
Browse Plan Formulary |
Anthem MediBlue Diabetes Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:900 /30Days | $487.50 |
Browse Plan Formulary |
Anthem MediBlue Diabetes Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:900 /30Days | $487.50 |
Browse Plan Formulary |
Anthem MediBlue ESRD Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:900 /30Days | $487.50 |
Browse Plan Formulary |
Anthem MediBlue ESRD Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:900 /30Days | $487.50 |
Browse Plan Formulary |
Anthem MediBlue Heart Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:900 /30Days | $487.50 |
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 |
Anthem MediBlue Heart Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:900 /30Days | $487.50 |
Browse Plan Formulary |
Anthem MediBlue Lung Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:900 /30Days | $487.50 |
Browse Plan Formulary |
Anthem MediBlue Lung Care (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:900 /30Days | $487.50 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:900 /30Days | $273.00 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:900 /30Days | $273.00 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:900 /30Days | $288.00 |
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 |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:900 /30Days | $288.00 |
Browse Plan Formulary |
Anthem MediBlue StartSmart Plus (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:900 /30Days | $487.50 |
Browse Plan Formulary |
Anthem MediBlue StartSmart Plus (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:900 /30Days | $487.50 |
Browse Plan Formulary |
Anthem MediBlue Value Plus (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:900 /30Days | $487.50 |
Browse Plan Formulary |
Anthem MediBlue Value Plus (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:900 /30Days | $487.50 |
Browse Plan Formulary |
AVA (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | P Q:750 /30Days | $399.00 |
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 |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | P Q:750 /30Days | $399.00 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | Q:25 /1Days | $793.50 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | Q:25 /1Days | $793.50 |
Browse Plan Formulary |
Blue Shield 65 Plus Plan 2 (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | Q:25 /1Days | $793.50 |
Browse Plan Formulary |
Blue Shield 65 Plus Plan 2 (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | Q:25 /1Days | $793.50 |
Browse Plan Formulary |
Blue Shield AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | Q:25 /1Days | $793.50 |
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 |
Blue Shield AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | Q:25 /1Days | $793.50 |
Browse Plan Formulary |
Blue Shield Inspire (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | Q:25 /1Days | $793.50 |
Browse Plan Formulary |
Blue Shield Inspire (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | Q:25 /1Days | $793.50 |
Browse Plan Formulary |
Blue Shield Promise Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | Q:25 /1Days | $793.50 |
Browse Plan Formulary |
Blue Shield Promise Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | Q:25 /1Days | $793.50 |
Browse Plan Formulary |
Blue Shield Vital (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | Q:25 /1Days | $793.50 |
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 |
Blue Shield Vital (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | Q:25 /1Days | $793.50 |
Browse Plan Formulary |
Brand New Day Bridges Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Brand New Day Bridges Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Brand New Day Classic Care I Plan (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Brand New Day Classic Care I Plan (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Brand New Day Classic Care II Plan (HMO)
|
$0.00 |
$50 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:900 /30Days | $268.50 |
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 |
Brand New Day Classic Care II Plan (HMO)
|
$0.00 |
$50 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Brand New Day Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | Q:900 /30Days | $268.50 |
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 |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | Q:900 /30Days | $268.50 |
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 |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | Q:900 /30Days | $268.50 |
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 |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | Q:900 /30Days | $268.50 |
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 | Q:900 /30Days | $268.50 |
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 |
Brand New Day Harmony Care Plan (HMO C-SNP)
|
$0.00 |
$100* |
No |
2* |
Generic |
$10.00 | $20.00 | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Brand New Day Select Care I Plan (HMO I-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Brand New Day Select Care I Plan (HMO I-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Central Health Focus Plan (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$75.00 | $150.00 | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Central Health Focus Plan (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$75.00 | $150.00 | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$75.00 | $150.00 | Q:900 /30Days | $268.50 |
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 |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$75.00 | $150.00 | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$5.00 | $10.00 | Q:900 /30Days | $268.50 |
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 | Q:900 /30Days | $268.50 |
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 | Q:900 /30Days | $268.50 |
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 | $616.50 |
Browse Plan Formulary |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
1 |
Tier 1 |
0% | 0% | None | $616.50 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:900 /30Days | $631.50 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:900 /30Days | $631.50 |
Browse Plan Formulary |
Health Net Jade (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:900 /30Days | $631.50 |
Browse Plan Formulary |
Health Net Jade (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:900 /30Days | $631.50 |
Browse Plan Formulary |
Heart & Diabetes (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$75.00 | $187.50 | P Q:750 /30Days | $396.00 |
Browse Plan Formulary |
Heart & Diabetes (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$75.00 | $187.50 | P Q:750 /30Days | $396.00 |
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 |
5 |
Specialty Tier |
33% | n/a | Q:750 /30Days | $225.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:750 /30Days | $225.00 |
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 | Q:750 /30Days | $369.00 |
Browse Plan Formulary |
Imperial Dynamic Plan (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$75.00 | $180.00 | Q:750 /30Days | $369.00 |
Browse Plan Formulary |
Imperial Senior Value (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:750 /30Days | $381.00 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Imperial Senior Value (HMO C-SNP)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:750 /30Days | $381.00 |
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 |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:750 /30Days | $381.00 |
Browse Plan Formulary |
Imperial Traditional (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:750 /30Days | $381.00 |
Browse Plan Formulary |
Inter Valley Health Plan Service To Seniors (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
25% | 25% | None | $253.50 |
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 | $405.00 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$10.00 | $20.00 | None | $405.00 |
Browse Plan Formulary |
L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
1 |
Tier 1 |
0% | 0% | P | $220.50 |
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% | P | $220.50 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | Q:900 /30Days | $793.50 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | Q:900 /30Days | $793.50 |
Browse Plan Formulary |
My Choice (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:750 /30Days | $400.50 |
Browse Plan Formulary |
My Choice (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:750 /30Days | $400.50 |
Browse Plan Formulary |
PHP (HMO C-SNP)
|
$0.00 |
$445 |
No |
1 |
Generic |
15% | n/a | Q:900 /30Days | $268.50 |
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 |
PHP (HMO C-SNP)
|
$0.00 |
$445 |
No |
1 |
Generic |
15% | n/a | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Platinum (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$75.00 | $187.50 | P Q:750 /30Days | $396.00 |
Browse Plan Formulary |
Platinum (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$75.00 | $187.50 | P Q:750 /30Days | $396.00 |
Browse Plan Formulary |
SCAN Balance (HMO C-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$30.00 | $70.00 | S | $441.00 |
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 | S | $441.00 |
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 | S | $457.50 |
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 |
3 |
Preferred Brand |
$37.00 | $91.00 | S | $457.50 |
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 | S | $439.50 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO I-SNP)
|
$0.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $126.00 | S | $439.50 |
Browse Plan Formulary |
smartHMO (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:750 /30Days | $399.00 |
Browse Plan Formulary |
smartHMO (HMO)
|
$0.00 |
$0 |
No |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:750 /30Days | $399.00 |
Browse Plan Formulary |
WellCare Best (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:900 /30Days | $171.00 |
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 |
WellCare Best (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:900 /30Days | $171.00 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:900 /30Days | $183.00 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:900 /30Days | $183.00 |
Browse Plan Formulary |
WellCare Freedom (HMO D-SNP)
|
$4.20 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | Q:900 /30Days | $168.00 |
Browse Plan Formulary |
WellCare Freedom (HMO D-SNP)
|
$4.20 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | Q:900 /30Days | $168.00 |
Browse Plan Formulary |
WellCare Plus (HMO)
|
$6.70 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | Q:900 /30Days | $168.00 |
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 |
WellCare Plus (HMO)
|
$6.70 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | Q:900 /30Days | $168.00 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$12.20 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:900 /30Days | $273.00 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$12.20 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:900 /30Days | $273.00 |
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 | Q:900 /30Days | $631.50 |
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 | Q:900 /30Days | $631.50 |
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 | Q:750 /30Days | $325.50 |
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. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:750 /30Days | $325.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
CalPlus (HMO)
|
$20.10 |
$445 |
No |
4 |
Non-Preferred Drug |
23% | 23% | P Q:750 /30Days | $402.00 |
Browse Plan Formulary |
CalPlus (HMO)
|
$20.10 |
$445 |
No |
4 |
Non-Preferred Drug |
23% | 23% | P Q:750 /30Days | $402.00 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$20.40 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | Q:750 /30Days | $225.00 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$20.40 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | Q:750 /30Days | $225.00 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Assure (HMO)
|
$22.50 |
$445 |
No |
4 |
Tier 4 |
25% | 25% | Q:750 /30Days | $307.50 |
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 |
UnitedHealthcare Medicare Advantage Assure (HMO)
|
$22.50 |
$445 |
No |
4 |
Tier 4 |
25% | 25% | Q:750 /30Days | $307.50 |
Browse Plan Formulary |
Anthem MediBlue Connect (HMO D-SNP)
|
$23.30 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:900 /30Days | $487.50 |
Browse Plan Formulary |
Anthem MediBlue Connect (HMO D-SNP)
|
$23.30 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:900 /30Days | $487.50 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$23.50 |
$445 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | 25% | Q:900 /30Days | $487.50 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$23.50 |
$445 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | 25% | Q:900 /30Days | $501.00 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$23.50 |
$445 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | 25% | Q:900 /30Days | $487.50 |
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 |
Anthem MediBlue Connect Plus (HMO)
|
$23.50 |
$445 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | 25% | Q:900 /30Days | $487.50 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$23.50 |
$445 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | 25% | Q:900 /30Days | $501.00 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$23.50 |
$445 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | 25% | Q:900 /30Days | $487.50 |
Browse Plan Formulary |
SCAN Prime (HMO)
|
$25.00 |
$0 |
No |
3 |
Preferred Brand |
$37.00 | $91.00 | S | $457.50 |
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 | S | $457.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Health Net Sapphire Premier (HMO)
|
$25.40 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | Q:900 /30Days | $534.00 |
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 |
Health Net Sapphire Premier (HMO)
|
$25.40 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | Q:900 /30Days | $534.00 |
Browse Plan Formulary |
Health Net Amber II (HMO D-SNP)
|
$26.60 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | Q:900 /30Days | $535.50 |
Browse Plan Formulary |
Health Net Amber II (HMO D-SNP)
|
$26.60 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | Q:900 /30Days | $535.50 |
Browse Plan Formulary |
Health Net Sapphire Premier II (HMO)
|
$26.70 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | Q:900 /30Days | $534.00 |
Browse Plan Formulary |
Health Net Sapphire Premier II (HMO)
|
$26.70 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | Q:900 /30Days | $534.00 |
Browse Plan Formulary |
Health Net Amber I (HMO D-SNP)
|
$27.80 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | Q:900 /30Days | $535.50 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Health Net Amber I (HMO D-SNP)
|
$27.80 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | Q:900 /30Days | $535.50 |
Browse Plan Formulary |
Health Net Sapphire (HMO)
|
$28.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | Q:900 /30Days | $535.50 |
Browse Plan Formulary |
Health Net Sapphire (HMO)
|
$28.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | Q:900 /30Days | $535.50 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$28.90 |
$0 |
No |
2 |
Tier 2 |
$15.00 | $30.00 | None | $403.50 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$28.90 |
$0 |
No |
2 |
Tier 2 |
$15.00 | $30.00 | None | $403.50 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP)
|
$30.50 |
$445 |
No |
2 |
Tier 2 |
15% | 15% | None | $403.50 |
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 |
Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP)
|
$30.50 |
$445 |
No |
2 |
Tier 2 |
15% | 15% | None | $403.50 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:900 /30Days | $279.00 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:900 /30Days | $279.00 |
Browse Plan Formulary |
Blue Shield Coordinated Choice Plan (HMO)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:25 /1Days | $793.50 |
Browse Plan Formulary |
Blue Shield Coordinated Choice Plan (HMO)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:25 /1Days | $793.50 |
Browse Plan Formulary |
Blue Shield TotalDual Plan (HMO D-SNP)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:25 /1Days | $793.50 |
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 |
Blue Shield TotalDual Plan (HMO D-SNP)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:25 /1Days | $793.50 |
Browse Plan Formulary |
Brand New Day Bridges Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Brand New Day Bridges Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Brand New Day Classic Choice Plan (HMO)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Brand New Day Classic Choice Plan (HMO)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Brand New Day Dual Access Plan (HMO D-SNP)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:900 /30Days | $268.50 |
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 |
Brand New Day Dual Access Plan (HMO D-SNP)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Brand New Day Harmony Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:900 /30Days | $268.50 |
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 |
Brand New Day Harmony Choice Plan (HMO C-SNP)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Brand New Day Select Choice I Plan (HMO I-SNP)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Brand New Day Select Choice I Plan (HMO I-SNP)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO D-SNP)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO D-SNP)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:900 /30Days | $268.50 |
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 |
Central Health Premier Plan (HMO)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Clever Care Balance Medicare Advantage (HMO)
|
$31.50 |
$435 |
No |
2 |
Generic |
25% | 25% | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Clever Care Balance Medicare Advantage (HMO)
|
$31.50 |
$435 |
No |
2 |
Generic |
25% | 25% | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Clever Care Balance Medicare Advantage (HMO)
|
$31.50 |
$435 |
No |
2 |
Generic |
25% | 25% | Q:900 /30Days | $268.50 |
Browse Plan Formulary |
Imperial Traditional Plus (HMO)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:750 /30Days | $381.00 |
Browse Plan Formulary |
Imperial Traditional Plus (HMO)
|
$31.50 |
$445 |
No |
4 |
Non-Preferred Drug |
25% | 25% | Q:750 /30Days | $381.00 |
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 |
Inter Valley Health Plan Vitality Plus (HMO)
|
$31.50 |
$445 |
No |
2 |
Generic |
25% | 25% | None | $253.50 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$31.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | Q:900 /30Days | $793.50 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$31.50 |
$445 |
No |
5 |
Specialty Tier |
25% | n/a | Q:900 /30Days | $793.50 |
Browse Plan Formulary |
SCAN Connections (HMO D-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | S | $448.50 |
Browse Plan Formulary |
SCAN Connections (HMO D-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | S | $448.50 |
Browse Plan Formulary |
SCAN Connections at Home (HMO D-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | S | $448.50 |
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 |
SCAN Connections at Home (HMO D-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | S | $448.50 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | S | $439.50 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | S | $439.50 |
Browse Plan Formulary |
VillageHealth (HMO-POS C-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | S | $457.50 |
Browse Plan Formulary |
VillageHealth (HMO-POS C-SNP)
|
$31.50 |
$445 |
No |
3 |
Preferred Brand |
25% | 25% | S | $457.50 |
Browse Plan Formulary |
SCAN Classic II (HMO)
|
$59.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $106.00 | S | $457.50 |
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 |
SCAN Classic II (HMO)
|
$59.00 |
$0 |
No |
3 |
Preferred Brand |
$42.00 | $106.00 | S | $457.50 |
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 | Q:900 /30Days | $156.00 |
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 | Q:900 /30Days | $156.00 |
Browse Plan Formulary |