MESALAMINE ER 0.375 GRAM CAPSULE 24H [Apriso] (120 CAPSULES ) (NDC: 68682011320)
2022 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 SecureHorizons Plan 4 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:120 /30Days | $224.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Align Connect (HMO C-SNP)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $45.00 | None | $336.00 |
Browse Plan Formulary |
Align Thrive (HMO I-SNP)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $45.00 | None | $336.00 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $147.60 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | None | $147.60 |
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 |
Astiva Health Advantage (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $350.40 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
AVA (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | Q:120 /30Days | $374.40 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | $87.50 | Q:4 /1Days | $136.80 |
Browse Plan Formulary |
Blue Shield AdvantageOptimum Plan 1 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:4 /1Days | $136.80 |
Browse Plan Formulary |
Blue Shield AdvantageOptimum Plan 2 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | Q:4 /1Days | $136.80 |
Browse Plan Formulary |
Blue Shield Promise Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
All Generics, All Brands |
2 |
Tier 2 |
0% | 0% | Q:4 /1Days | $136.80 |
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 |
Brand New Day Bridges Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $294.00 |
Browse Plan Formulary |
Brand New Day Classic Care I Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $294.00 |
Browse Plan Formulary |
Brand New Day Classic Care II Plan (HMO)
|
$0.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $294.00 |
Browse Plan Formulary |
Brand New Day Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $294.00 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Brand New Day Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $294.00 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Brand New Day Harmony Care Plan (HMO C-SNP)
|
$0.00 |
$100 |
Some Generics |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $294.00 |
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 |
Brand New Day Part B Savings Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $294.00 |
Browse Plan Formulary |
Brand New Day Select Care II Plan (HMO I-SNP)
|
$0.00 |
$0 |
Some Generics |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $294.00 |
Browse Plan Formulary |
CalPlus (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | Q:120 /30Days | $375.60 |
Browse Plan Formulary |
Clever Care Fortune Medicare Advantage Plan (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $294.00 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Fortune Medicare Advantage Plan (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $296.40 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Fortune Medicare Advantage Plan (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $294.00 |
Browse Plan Formulary select insulin pay $0-$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 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $294.00 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $296.40 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $294.00 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Value Medicare Advantage Plan (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$10.00 | $20.00 | None | $294.00 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Value Medicare Advantage Plan (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$10.00 | $20.00 | None | $296.40 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Value Medicare Advantage Plan (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$10.00 | $20.00 | None | $294.00 |
Browse Plan Formulary select insulin pay $0-$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 |
CommuniCare Advantage Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
All Generics, All Brands |
1 |
Tier 1 |
0% | 0% | None | $294.00 |
Browse Plan Formulary |
Harmony (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | Q:120 /30Days | $382.80 |
Browse Plan Formulary |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
All Generics, All Brands |
1 |
Tier 1 |
0% | 0% | Q:120 /30Days | $139.20 |
Browse Plan Formulary |
Heart & Diabetes (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics |
4 |
Non-Preferred Drug |
$75.00 | $187.50 | Q:120 /30Days | $374.40 |
Browse Plan Formulary |
Humana Gold Plus H5619-016 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:120 /30Days | $319.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Imperial Dynamic Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $180.00 | None | $358.80 |
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 Senior Value (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $360.00 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Imperial Strong (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $360.00 |
Browse Plan Formulary |
Imperial Traditional (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $360.00 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Kaiser Permanente Senior Advantage San Diego (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$7.00 | $14.00 | None | $255.60 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
All Generics, All Brands |
1 |
Tier 1 |
0% | 0% | Q:120 /30Days | $181.20 |
Browse Plan Formulary |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$12.00 | $24.00 | Q:120 /30Days | $259.20 |
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 |
Molina Medicare Choice Care Select (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $40.00 | Q:120 /30Days | $259.20 |
Browse Plan Formulary |
Platinum (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $225.00 | Q:120 /30Days | $392.40 |
Browse Plan Formulary |
SCAN Alta (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $265.00 | Q:120 /30Days | $396.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Scripps Classic offered by SCAN Health Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $265.00 | Q:120 /30Days | $396.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$93.00 | $279.00 | Q:120 /30Days | $392.40 |
Browse Plan Formulary |
Sharp Direct Advantage Gold Card (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $0.00 | Q:120 /30Days | $148.80 |
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 |
Sharp Direct Advantage VIP Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $0.00 | Q:120 /30Days | $148.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Sharp SecureHorizons Plan by UnitedHealthcare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:120 /30Days | $224.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Sharp Walgreens by UnitedHealthcare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:120 /30Days | $224.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
the ONE + Rite Aid (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:120 /30Days | $374.40 |
Browse Plan Formulary |
UC San Diego Health Humana (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:120 /30Days | $319.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Chronic Complete Focus (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:120 /30Days | $224.40 |
Browse Plan Formulary select insulin pay $25 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 |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:120 /30Days | $324.00 |
Browse Plan Formulary |
Wellcare Specialty No Premium (HMO C-SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $0.00 | Q:120 /30Days | $332.40 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Anthem MediBlue Coordination Plus (HMO)
|
$3.70 |
$480 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $147.60 |
Browse Plan Formulary |
AVA (PPO)
|
$22.50 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:120 /30Days | $373.20 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$22.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:120 /30Days | $319.20 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Assure (HMO)
|
$24.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | Q:120 /30Days | $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 |
AARP Medicare Advantage SecureHorizons Value (HMO)
|
$25.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:120 /30Days | $224.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Anthem MediBlue Extra (HMO)
|
$25.70 |
$480 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $259.20 |
Browse Plan Formulary |
Scripps Heart First offered by SCAN Health Plan (HMO C-SNP)
|
$26.00 |
$0 |
Some Generics |
4 |
Non-Preferred Drug |
$95.00 | $265.00 | Q:120 /30Days | $396.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Align Premier (HMO I-SNP)
|
$26.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $336.00 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$27.30 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Tier 2 |
$15.00 | $30.00 | None | $244.80 |
Browse Plan Formulary |
Kaiser Permanente Sr Adv Medicare Medi-Cal (HMO D-SNP)
|
$31.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $255.60 |
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)
|
$32.20 |
$480 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | 25% | None | $294.00 |
Browse Plan Formulary |
Anthem MediBlue ESRD Care (PPO C-SNP)
|
$33.20 |
$130 |
Few Generics |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $213.60 |
Browse Plan Formulary |
Astiva Health Value (HMO)
|
$33.20 |
$480 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | 25% | None | $350.40 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Blue Shield Coordinated Choice Plan (HMO)
|
$33.20 |
$480 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
25% | 25% | Q:4 /1Days | $228.00 |
Browse Plan Formulary |
Blue Shield TotalDual Plan (HMO D-SNP)
|
$33.20 |
$480 |
Few Generics |
3 |
Preferred Brand |
25% | 25% | Q:4 /1Days | $207.60 |
Browse Plan Formulary |
Brand New Day Bridges Choice Plan (HMO C-SNP)
|
$33.20 |
$480 |
Some Generics |
4 |
Non-Preferred Drug |
25% | 25% | None | $294.00 |
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 |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$33.20 |
$480 |
Some Generics |
4 |
Non-Preferred Drug |
25% | 25% | None | $294.00 |
Browse Plan Formulary |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$33.20 |
$480 |
Some Generics |
4 |
Non-Preferred Drug |
25% | 25% | None | $294.00 |
Browse Plan Formulary |
Brand New Day Harmony Choice Plan (HMO C-SNP)
|
$33.20 |
$480 |
Some Generics |
4 |
Non-Preferred Drug |
25% | 25% | None | $294.00 |
Browse Plan Formulary |
Brand New Day Select Choice II Plan (HMO I-SNP)
|
$33.20 |
$480 |
Some Generics |
4 |
Non-Preferred Drug |
25% | 25% | None | $294.00 |
Browse Plan Formulary |
Clever Care Balance Medicare Advantage (HMO)
|
$33.20 |
$480 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
25% | 25% | None | $294.00 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Balance Medicare Advantage (HMO)
|
$33.20 |
$480 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
25% | 25% | None | $296.40 |
Browse Plan Formulary select insulin pay $0-$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 Balance Medicare Advantage (HMO)
|
$33.20 |
$480 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
25% | 25% | None | $294.00 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Imperial Traditional Plus (HMO)
|
$33.20 |
$480 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | 25% | None | $360.00 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$33.20 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
30% | 30% | Q:120 /30Days | $258.00 |
Browse Plan Formulary |
Scripps Plus offered by SCAN Health Plan (HMO)
|
$33.20 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | Q:120 /30Days | $396.00 |
Browse Plan Formulary |
Wellcare Dual Liberty (HMO D-SNP)
|
$33.20 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
44% | 44% | Q:120 /30Days | $207.60 |
Browse Plan Formulary |
Wellcare Plus Sapphire I (HMO)
|
$33.20 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
46% | 46% | Q:120 /30Days | $211.20 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Wellcare Plus Sapphire II (HMO)
|
$33.20 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
44% | 44% | Q:120 /30Days | $208.80 |
Browse Plan Formulary |
Sharp Direct Advantage Platinum Card (HMO)
|
$58.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $0.00 | Q:120 /30Days | $148.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage SecureHorizons Premier (HMO)
|
$69.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $131.00 | Q:120 /30Days | $224.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Scripps Signature offered by SCAN Health Plan (HMO)
|
$74.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $265.00 | Q:120 /30Days | $396.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |