ZOLMITRIPTAN 2.5 MG TABLET [Zomig] (6 TABLETS ) (NDC: 27241002168)
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 |
Aetna Medicare Plus Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$99.00 | $297.00 | Q:6 /30Days | $87.24 |
Browse Plan Formulary |
Aetna Medicare Plus Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$99.00 | $297.00 | Q:6 /30Days | $87.24 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:6 /30Days | $87.66 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:6 /30Days | $87.66 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:6 /30Days | $87.24 |
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 Select Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:6 /30Days | $87.24 |
Browse Plan Formulary |
Align Connect (HMO C-SNP)
|
$0.00 |
$480 |
No |
2 |
Generic |
$15.00 | $45.00 | Q:18 /30Days | $16.62 |
Browse Plan Formulary |
Align Connect (HMO C-SNP)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $45.00 | Q:18 /30Days | $16.62 |
Browse Plan Formulary |
Align Thrive (HMO I-SNP)
|
$0.00 |
$480 |
No |
2 |
Generic |
$15.00 | $45.00 | Q:18 /30Days | $16.62 |
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 | Q:18 /30Days | $16.62 |
Browse Plan Formulary |
Anthem Blue Cross Cal MediConnect (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | Q:9 /30Days | $117.30 |
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 Blue Cross Cal MediConnect (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
All Generics, All Brands |
2 |
Tier 2 |
0% | 0% | Q:9 /30Days | $117.30 |
Browse Plan Formulary |
Anthem MediBlue Care On Site (HMO I-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$9.50 | $0.00 | Q:9 /30Days | $133.80 |
Browse Plan Formulary |
Anthem MediBlue Care On Site (HMO I-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
2 |
Generic |
$9.50 | $0.00 | Q:9 /30Days | $133.80 |
Browse Plan Formulary |
Anthem MediBlue Diabetes Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$7.50 | $0.00 | Q:9 /30Days | $95.10 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Anthem MediBlue Diabetes Care (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
2 |
Generic |
$7.50 | $0.00 | Q:9 /30Days | $95.10 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Anthem MediBlue ESRD Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$7.50 | $0.00 | Q:9 /30Days | $95.10 |
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 ESRD Care (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
2 |
Generic |
$7.50 | $0.00 | Q:9 /30Days | $95.10 |
Browse Plan Formulary |
Anthem MediBlue Heart Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$7.50 | $0.00 | Q:9 /30Days | $95.10 |
Browse Plan Formulary |
Anthem MediBlue Heart Care (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
2 |
Generic |
$7.50 | $0.00 | Q:9 /30Days | $95.10 |
Browse Plan Formulary |
Anthem MediBlue Lung Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$7.50 | $0.00 | Q:9 /30Days | $95.10 |
Browse Plan Formulary |
Anthem MediBlue Lung Care (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
2 |
Generic |
$7.50 | $0.00 | Q:9 /30Days | $95.10 |
Browse Plan Formulary |
Anthem MediBlue StartSmart Plus (HMO)
|
$0.00 |
$0 |
No |
2 |
Generic |
$14.50 | $0.00 | Q:9 /30Days | $93.12 |
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 StartSmart Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$14.50 | $0.00 | Q:9 /30Days | $93.12 |
Browse Plan Formulary |
Anthem MediBlue Value Plus (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$9.50 | $0.00 | Q:9 /30Days | $95.10 |
Browse Plan Formulary |
Anthem MediBlue Value Plus (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$9.50 | $0.00 | Q:9 /30Days | $95.10 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $7.50 | Q:18 /30Days | $42.54 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $7.50 | Q:18 /30Days | $42.54 |
Browse Plan Formulary |
Blue Shield 65 Plus Plan 2 (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$10.00 | $15.00 | Q:18 /30Days | $42.54 |
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 Plan 2 (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$10.00 | $15.00 | Q:18 /30Days | $42.54 |
Browse Plan Formulary |
Blue Shield AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | Q:18 /30Days | $42.54 |
Browse Plan Formulary |
Blue Shield AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | Q:18 /30Days | $42.54 |
Browse Plan Formulary |
Blue Shield Balance (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | Q:18 /30Days | $42.54 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Blue Shield Balance (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | Q:18 /30Days | $42.54 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Blue Shield Inspire (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | Q:18 /30Days | $42.54 |
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 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $237.50 | Q:18 /30Days | $42.54 |
Browse Plan Formulary |
Blue Shield Promise Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | Q:18 /30Days | $42.54 |
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:18 /30Days | $42.54 |
Browse Plan Formulary |
Blue Shield TotalDual Plan (HMO D-SNP)
|
$0.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | 25% | Q:18 /30Days | $42.54 |
Browse Plan Formulary |
Central Health Focus Plan (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $150.00 | Q:6 /30Days | $14.34 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Central Health Focus Plan (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
4 |
Non-Preferred Drug |
$75.00 | $150.00 | Q:6 /30Days | $14.34 |
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 |
Central Health Medi-Medi Plan (HMO D-SNP)
|
$0.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | 25% | Q:6 /30Days | $14.34 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $150.00 | Q:6 /30Days | $14.34 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $150.00 | Q:6 /30Days | $14.34 |
Browse Plan Formulary |
Central Health Savings Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$99.00 | $198.00 | Q:6 /30Days | $14.34 |
Browse Plan Formulary |
Central Health Savings Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$99.00 | $198.00 | Q:6 /30Days | $14.34 |
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 | Q:6 /30Days | $15.48 |
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, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:6 /30Days | $14.34 |
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 | Q:6 /30Days | $14.34 |
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 | Q:6 /30Days | $15.48 |
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 | Q:6 /30Days | $14.34 |
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 | Q:6 /30Days | $14.34 |
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 | Q:6 /30Days | $15.48 |
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, this drug has Gap Coverage. |
2 |
Generic |
$10.00 | $20.00 | Q:6 /30Days | $14.34 |
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 | Q:6 /30Days | $14.34 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
1 |
Tier 1 |
0% | 0% | Q:12 /30Days | $30.24 |
Browse Plan Formulary |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
All Generics, All Brands |
1 |
Tier 1 |
0% | 0% | Q:12 /30Days | $30.24 |
Browse Plan Formulary |
Imperial Dynamic Plan (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$3.00 | $5.00 | Q:6 /30Days | $45.06 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Imperial Dynamic Plan (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$3.00 | $5.00 | Q:6 /30Days | $45.06 |
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 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $10.00 | Q:6 /30Days | $45.66 |
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 |
2 |
Generic |
$5.00 | $10.00 | Q:6 /30Days | $45.66 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Imperial Strong (HMO)
|
$0.00 |
$480 |
No |
2 |
Tier 2 |
25% | 25% | Q:6 /30Days | $45.66 |
Browse Plan Formulary |
Imperial Strong (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | Q:6 /30Days | $45.66 |
Browse Plan Formulary |
Imperial Traditional (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $10.00 | Q:6 /30Days | $45.66 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Imperial Traditional (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $10.00 | Q:6 /30Days | $45.66 |
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 |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $10.00 | None | $15.72 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $10.00 | None | $15.72 |
Browse Plan Formulary |
L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
1 |
Tier 1 |
0% | 0% | Q:18 /30Days | $32.58 |
Browse Plan Formulary |
L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
All Generics, All Brands |
1 |
Tier 1 |
0% | 0% | Q:18 /30Days | $32.58 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
1 |
Tier 1 |
0% | 0% | Q:12 /30Days | $43.98 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
All Generics, All Brands |
1 |
Tier 1 |
0% | 0% | Q:12 /30Days | $43.98 |
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 Medicare Choice Care (HMO)
|
$0.00 |
$125 |
No |
2 |
Generic |
$12.00 | $24.00 | Q:12 /30Days | $49.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$12.00 | $24.00 | Q:12 /30Days | $49.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Molina Medicare Choice Care Select (HMO)
|
$0.00 |
$480 |
No |
2 |
Generic |
$20.00 | $40.00 | Q:12 /30Days | $49.20 |
Browse Plan Formulary |
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:12 /30Days | $49.20 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$0.00 |
$480 |
No |
4 |
Non-Preferred Drug |
30% | 30% | Q:12 /30Days | $49.20 |
Browse Plan Formulary |
SCAN Balance (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | $70.00 | None | $47.52 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SCAN Balance (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
3 |
Preferred Brand |
$30.00 | $70.00 | None | $47.52 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
SCAN Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | $70.00 | None | $46.92 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SCAN Classic (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | $70.00 | None | $46.92 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SCAN Connections (HMO D-SNP)
|
$0.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
25% | 25% | None | $47.58 |
Browse Plan Formulary |
SCAN Connections at Home (HMO D-SNP)
|
$0.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
25% | 25% | None | $47.58 |
Browse Plan Formulary |
SCAN Embrace (HMO I-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $91.00 | None | $46.92 |
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 Embrace (HMO I-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
3 |
Preferred Brand |
$37.00 | $91.00 | None | $46.92 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
SCAN Healthy at Home (HMO I-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $47.94 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SCAN Healthy at Home (HMO I-SNP)
|
$0.00 |
$0 |
Some Generics |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $47.94 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SCAN Prime (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | $70.00 | None | $46.92 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SCAN Venture (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | $70.00 | None | $47.52 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SCAN Venture (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | $70.00 | None | $47.52 |
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 |
Wellcare Dual Liberty (HMO D-SNP)
|
$0.00 |
$480 |
No |
4 |
Non-Preferred Drug |
44% | 44% | Q:12 /30Days | $152.82 |
Browse Plan Formulary |
Wellcare Dual Liberty Freedom (HMO D-SNP)
|
$0.00 |
$480 |
No |
4 |
Non-Preferred Drug |
42% | 42% | Q:12 /30Days | $207.90 |
Browse Plan Formulary |
Wellcare Dual Liberty Freedom (HMO D-SNP)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
42% | 42% | Q:12 /30Days | $207.90 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $0.00 | Q:12 /30Days | $143.58 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $0.00 | Q:12 /30Days | $143.58 |
Browse Plan Formulary |
Wellcare Giveback Focus (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $0.00 | Q:12 /30Days | $147.96 |
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 |
Wellcare Giveback Focus (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $0.00 | Q:12 /30Days | $147.96 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Wellcare Low Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:12 /30Days | $166.68 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:12 /30Days | $161.46 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:12 /30Days | $161.46 |
Browse Plan Formulary |
Wellcare No Premium Best (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | Q:12 /30Days | $150.96 |
Browse Plan Formulary |
Wellcare No Premium Best (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | Q:12 /30Days | $150.96 |
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)
|
$0.00 |
$480 |
No |
4 |
Non-Preferred Drug |
42% | 42% | Q:12 /30Days | $211.44 |
Browse Plan Formulary |
Wellcare Plus (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
42% | 42% | Q:12 /30Days | $211.44 |
Browse Plan Formulary |
Wellcare Specialty No Premium (HMO C-SNP)
|
$0.00 |
$0 |
No |
2 |
Generic |
$8.00 | $0.00 | Q:12 /30Days | $158.40 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Wellcare Specialty No Premium (HMO C-SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $0.00 | Q:12 /30Days | $158.40 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Wellcare Low Premium (HMO)
|
$18.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:12 /30Days | $166.68 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$21.50 |
$480 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
25% | 0% | Q:9 /30Days | $93.06 |
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)
|
$21.50 |
$480 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
25% | 0% | Q:9 /30Days | $93.06 |
Browse Plan Formulary |
Anthem MediBlue Connect (HMO D-SNP)
|
$22.00 |
$480* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$0.00 | $0.00 | Q:9 /30Days | $95.52 |
Browse Plan Formulary |
Anthem MediBlue Connect (HMO D-SNP)
|
$22.00 |
$480* |
Many Generics, Some Brands |
2* |
Generic |
$0.00 | $0.00 | Q:9 /30Days | $95.52 |
Browse Plan Formulary |
SCAN Prime (HMO)
|
$25.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | $70.00 | None | $46.92 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Align Premier (HMO I-SNP)
|
$26.70 |
$480 |
No |
1 |
Tier 1 |
25% | 25% | Q:18 /30Days | $16.62 |
Browse Plan Formulary |
Align Premier (HMO I-SNP)
|
$26.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:18 /30Days | $16.62 |
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)
|
$27.30 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Tier 2 |
$15.00 | $30.00 | None | $30.90 |
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 | $30.90 |
Browse Plan Formulary |
Kaiser Permanente Sr Adv Medicare Medi-Cal (HMO D-SNP)
|
$31.40 |
$480 |
No |
2 |
Tier 2 |
15% | 15% | None | $24.36 |
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 | $24.36 |
Browse Plan Formulary |
Blue Shield Coordinated Choice Plan (HMO)
|
$33.20 |
$480 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | 25% | Q:18 /30Days | $42.54 |
Browse Plan Formulary |
Blue Shield Coordinated Choice Plan (HMO)
|
$33.20 |
$480 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | 25% | Q:18 /30Days | $42.54 |
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)
|
$33.20 |
$480 |
Few Generics |
4 |
Non-Preferred Drug |
25% | 25% | Q:18 /30Days | $42.54 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO D-SNP)
|
$33.20 |
$480 |
Many Generics, Some Brands |
4 |
Non-Preferred Drug |
25% | 25% | Q:6 /30Days | $14.34 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$33.20 |
$480 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | 25% | Q:6 /30Days | $14.34 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$33.20 |
$480 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
25% | 25% | Q:6 /30Days | $14.34 |
Browse Plan Formulary |
Clever Care Balance Medicare Advantage (HMO)
|
$33.20 |
$480 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
25% | 25% | Q:6 /30Days | $15.48 |
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% | Q:6 /30Days | $14.34 |
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% | Q:6 /30Days | $14.34 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Imperial Traditional Plus (HMO)
|
$33.20 |
$480 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
25% | 25% | Q:6 /30Days | $45.66 |
Browse Plan Formulary |
Imperial Traditional Plus (HMO)
|
$33.20 |
$480 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
25% | 25% | Q:6 /30Days | $45.66 |
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:12 /30Days | $49.20 |
Browse Plan Formulary |
SCAN Connections (HMO D-SNP)
|
$33.20 |
$480 |
Some Generics |
3 |
Preferred Brand |
25% | 25% | None | $47.58 |
Browse Plan Formulary |
SCAN Connections at Home (HMO D-SNP)
|
$33.20 |
$480 |
Some Generics |
3 |
Preferred Brand |
25% | 25% | None | $47.58 |
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)
|
$33.20 |
$480 |
No |
3 |
Preferred Brand |
25% | 25% | None | $48.06 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$33.20 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | 25% | None | $48.06 |
Browse Plan Formulary |
VillageHealth (HMO-POS C-SNP)
|
$33.20 |
$480 |
No |
3 |
Preferred Brand |
25% | 25% | None | $46.92 |
Browse Plan Formulary |
VillageHealth (HMO-POS C-SNP)
|
$33.20 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | 25% | None | $46.92 |
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:12 /30Days | $152.82 |
Browse Plan Formulary |
Wellcare Plus Sapphire I (HMO)
|
$33.20 |
$480 |
No |
4 |
Non-Preferred Drug |
46% | 46% | Q:12 /30Days | $149.40 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Wellcare Plus Sapphire I (HMO)
|
$33.20 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
46% | 46% | Q:12 /30Days | $149.40 |
Browse Plan Formulary |
Wellcare Plus Sapphire II (HMO)
|
$33.20 |
$480 |
No |
4 |
Non-Preferred Drug |
44% | 44% | Q:12 /30Days | $153.60 |
Browse Plan Formulary |
Wellcare Plus Sapphire II (HMO)
|
$33.20 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
44% | 44% | Q:12 /30Days | $153.60 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$48.50 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:6 /30Days | $84.48 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$90.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:6 /30Days | $84.48 |
Browse Plan Formulary |