SPRYCEL 80mg/1 1 BOTTLE per CARTON / 30 TABLET BOTTLE (30 TAB BOTTLE in CARTON ) (NDC: 00003085522)
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. | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $16,872.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Plus Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $17,110.50 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $17,110.50 |
Browse Plan Formulary |
Align Connect (HMO C-SNP)
|
$0.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P | $16,939.50 |
Browse Plan Formulary |
Align Thrive (HMO I-SNP)
|
$0.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P | $16,939.50 |
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 Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $17,205.60 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $17,205.60 |
Browse Plan Formulary |
Astiva Health Advantage (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $16,106.40 |
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. | 5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $15,766.20 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:2 /1Days | $15,408.90 |
Browse Plan Formulary |
Blue Shield AdvantageOptimum Plan 1 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:2 /1Days | $15,408.90 |
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 2 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:2 /1Days | $15,408.90 |
Browse Plan Formulary |
Blue Shield Promise Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | All Generics, All Brands | 3 |
Tier 3 |
0% | 0% | P Q:2 /1Days | $15,408.90 |
Browse Plan Formulary |
Brand New Day Bridges Care Plan (HMO C-SNP)
|
$0.00 |
$0 | Some Generics | 5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $15,380.40 |
Browse Plan Formulary |
Brand New Day Classic Care I Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $15,380.40 |
Browse Plan Formulary |
Brand New Day Classic Care II Plan (HMO)
|
$0.00 |
$50 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
32% | n/a | P Q:30 /30Days | $15,380.40 |
Browse Plan Formulary |
Brand New Day Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 | Some Generics | 5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $15,380.40 |
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 |
Brand New Day Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 | Some Generics | 5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $15,380.40 |
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 | 5 |
Specialty Tier |
30% | n/a | P Q:30 /30Days | $15,380.40 |
Browse Plan Formulary |
Brand New Day Part B Savings Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $15,380.40 |
Browse Plan Formulary |
Brand New Day Select Care II Plan (HMO I-SNP)
|
$0.00 |
$0 | Some Generics | 5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $15,380.40 |
Browse Plan Formulary |
CalPlus (HMO)
|
$0.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $15,766.20 |
Browse Plan Formulary |
Clever Care Fortune Medicare Advantage Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days | $15,973.80 |
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 Fortune Medicare Advantage Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days | $15,380.40 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Fortune Medicare Advantage Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days | $15,380.40 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days | $15,380.40 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days | $15,973.80 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days | $15,380.40 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Value Medicare Advantage Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days | $15,380.40 |
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 Value Medicare Advantage Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days | $15,973.80 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Value Medicare Advantage Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | 33% | P Q:30 /30Days | $15,380.40 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
CommuniCare Advantage Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | All Generics, All Brands | 2 |
Tier 2 |
0% | 0% | P Q:30 /30Days | $15,380.40 |
Browse Plan Formulary |
Harmony (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $15,399.60 |
Browse Plan Formulary |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | All Generics, All Brands | 2 |
Tier 2 |
0% | 0% | P | $15,408.90 |
Browse Plan Formulary |
Heart & Diabetes (HMO C-SNP)
|
$0.00 |
$0 | Some Generics | 5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $15,766.20 |
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 |
Humana Gold Plus H5619-016 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $17,110.50 |
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. | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $15,984.30 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Imperial Senior Value (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $15,984.30 |
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 | 5 |
Tier 5 |
25% | 25% | P Q:60 /30Days | $15,984.30 |
Browse Plan Formulary |
Imperial Traditional (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $15,984.30 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Kaiser Permanente Senior Advantage San Diego (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | 33% | None | $15,944.70 |
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 | All Generics, All Brands | 2 |
Tier 2 |
0% | 0% | P | $15,408.90 |
Browse Plan Formulary |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
31% | n/a | P | $15,408.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Molina Medicare Choice Care Select (HMO)
|
$0.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P | $15,408.90 |
Browse Plan Formulary |
Platinum (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $15,399.60 |
Browse Plan Formulary |
SCAN Alta (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $15,740.10 |
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. | 5 |
Specialty Tier |
33% | n/a | P | $15,740.10 |
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 |
Select (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $15,399.60 |
Browse Plan Formulary |
Sharp Direct Advantage Gold Card (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $15,408.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Sharp Direct Advantage VIP Plan (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $15,408.90 |
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. | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $16,872.90 |
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. | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $15,304.50 |
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. | 5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $15,766.20 |
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 |
UC San Diego Health Humana (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $17,110.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Chronic Complete Focus (HMO C-SNP)
|
$0.00 |
$0 | Some Generics | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $16,872.90 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
Wellcare No Premium (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $16,730.40 |
Browse Plan Formulary |
Wellcare Specialty No Premium (HMO C-SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $16,730.40 |
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. | 5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $17,205.60 |
Browse Plan Formulary |
Aetna Medicare Plus Plan 2 (HMO)
|
$19.30 |
$220 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
29% | n/a | P Q:30 /30Days | $17,110.50 |
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 |
AVA (PPO)
|
$22.50 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $15,766.20 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$22.60 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $17,110.50 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Assure (HMO)
|
$24.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
25% | 25% | P Q:60 /30Days | $16,872.90 |
Browse Plan Formulary |
AARP Medicare Advantage SecureHorizons Value (HMO)
|
$25.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $16,872.90 |
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. | 5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $17,205.60 |
Browse Plan Formulary |
Scripps Heart First offered by SCAN Health Plan (HMO C-SNP)
|
$26.00 |
$0 | Some Generics | 5 |
Specialty Tier |
33% | n/a | P | $15,740.10 |
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 |
Align Premier (HMO I-SNP)
|
$26.70 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | P | $16,939.50 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$27.30 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Tier 5 |
33% | 33% | None | $15,944.70 |
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 | 5 |
Tier 5 |
15% | 15% | None | $15,944.70 |
Browse Plan Formulary |
Brand New Day Classic Choice Plan (HMO)
|
$32.20 |
$480 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $15,380.40 |
Browse Plan Formulary |
Anthem MediBlue ESRD Care (PPO C-SNP)
|
$33.20 |
$130 | Few Generics | 5 |
Specialty Tier |
30% | n/a | P Q:30 /30Days | $17,205.60 |
Browse Plan Formulary |
Astiva Health Value (HMO)
|
$33.20 |
$480 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $16,106.40 |
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 |
Blue Shield Coordinated Choice Plan (HMO)
|
$33.20 |
$480 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | n/a | P Q:2 /1Days | $15,408.90 |
Browse Plan Formulary |
Blue Shield TotalDual Plan (HMO D-SNP)
|
$33.20 |
$480 | Few Generics | 5 |
Specialty Tier |
25% | n/a | P Q:2 /1Days | $15,408.90 |
Browse Plan Formulary |
Brand New Day Bridges Choice Plan (HMO C-SNP)
|
$33.20 |
$480 | Some Generics | 5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $15,380.40 |
Browse Plan Formulary |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$33.20 |
$480 | Some Generics | 5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $15,380.40 |
Browse Plan Formulary |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$33.20 |
$480 | Some Generics | 5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $15,380.40 |
Browse Plan Formulary |
Brand New Day Harmony Choice Plan (HMO C-SNP)
|
$33.20 |
$480 | Some Generics | 5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $15,380.40 |
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 |
Brand New Day Select Choice II Plan (HMO I-SNP)
|
$33.20 |
$480 | Some Generics | 5 |
Specialty Tier |
25% | n/a | P Q:30 /30Days | $15,380.40 |
Browse Plan Formulary |
Clever Care Balance Medicare Advantage (HMO)
|
$33.20 |
$480 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days | $15,380.40 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Balance Medicare Advantage (HMO)
|
$33.20 |
$480 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days | $15,973.80 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Balance Medicare Advantage (HMO)
|
$33.20 |
$480 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
25% | 25% | P Q:30 /30Days | $15,380.40 |
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. | 5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $15,984.30 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$33.20 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P | $15,408.90 |
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 |
Scripps Plus offered by SCAN Health Plan (HMO)
|
$33.20 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P | $15,740.10 |
Browse Plan Formulary |
Wellcare Dual Liberty (HMO D-SNP)
|
$33.20 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P | $16,772.10 |
Browse Plan Formulary |
Wellcare Plus Sapphire I (HMO)
|
$33.20 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P | $16,770.60 |
Browse Plan Formulary |
Wellcare Plus Sapphire II (HMO)
|
$33.20 |
$480 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P | $16,772.10 |
Browse Plan Formulary |
Sharp Direct Advantage Platinum Card (HMO)
|
$58.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | n/a | P | $15,408.90 |
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. | 5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $16,872.90 |
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 |
Scripps Signature offered by SCAN Health Plan (HMO)
|
$74.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P | $15,740.10 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Choice Plan (PPO)
|
$90.00 |
$0 | Yes, but No Gap Coverage for this drug. | 5 |
Specialty Tier |
33% | n/a | P Q:30 /30Days | $17,110.50 |
Browse Plan Formulary |