SELZENTRY 300mg/1 60 FILM COATED TABLETS in BOTTLE (60 TABLET, FILM COATED ) (NDC: 49702022418)
2022 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
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Plan Name |
Monthly Prem. |
De- duct- ible |
Does Plan Offer Additional Gap Coverage |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Plan’s Avg. Retail Drug Price 30-Day |
Tier Nbr. |
Tier Desc. |
30-Day Prfrd. Pharm |
90-Day Mail Order |
AARP Medicare Advantage Freedom Plus (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,725.60 |
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. |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,725.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Harmony (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,725.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Harmony (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,725.60 |
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. |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,725.60 |
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 Focus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,725.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,725.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,725.60 |
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 | None | $1,764.00 |
Browse Plan Formulary |
Aetna Medicare Plus Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,764.00 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,764.00 |
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 |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,764.00 |
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 | None | $1,764.00 |
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 | None | $1,764.00 |
Browse Plan Formulary |
Align Connect (HMO C-SNP)
|
$0.00 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | None | $1,747.20 |
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 | None | $1,747.20 |
Browse Plan Formulary |
Align Thrive (HMO I-SNP)
|
$0.00 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | None | $1,747.20 |
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 |
Align Thrive (HMO I-SNP)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $1,747.20 |
Browse Plan Formulary |
Anthem Blue Cross Cal MediConnect (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | Q:120 /30Days | $1,569.00 |
Browse Plan Formulary |
Anthem Blue Cross Cal MediConnect (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
All Generics, All Brands |
2 |
Tier 2 |
0% | 0% | Q:120 /30Days | $1,569.00 |
Browse Plan Formulary |
Anthem MediBlue Care On Site (HMO I-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,569.00 |
Browse Plan Formulary |
Anthem MediBlue Care On Site (HMO I-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,569.00 |
Browse Plan Formulary |
Anthem MediBlue Diabetes Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,741.20 |
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 |
Anthem MediBlue Diabetes Care (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,741.20 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Anthem MediBlue Dual Advantage (HMO D-SNP)
|
$0.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | Q:120 /30Days | $1,732.80 |
Browse Plan Formulary |
Anthem MediBlue Dual Advantage (HMO D-SNP)
|
$0.00 |
$480 |
Few Generics |
5 |
Specialty Tier |
25% | n/a | Q:120 /30Days | $1,732.80 |
Browse Plan Formulary |
Anthem MediBlue ESRD Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,741.20 |
Browse Plan Formulary |
Anthem MediBlue ESRD Care (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,741.20 |
Browse Plan Formulary |
Anthem MediBlue Heart Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,741.20 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Anthem MediBlue Heart Care (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,741.20 |
Browse Plan Formulary |
Anthem MediBlue Lung Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,741.20 |
Browse Plan Formulary |
Anthem MediBlue Lung Care (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,741.20 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,741.20 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,741.20 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,741.20 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,741.20 |
Browse Plan Formulary |
Anthem MediBlue StartSmart Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,741.20 |
Browse Plan Formulary |
Anthem MediBlue StartSmart Plus (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,741.20 |
Browse Plan Formulary |
Anthem MediBlue Value Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,741.20 |
Browse Plan Formulary |
Anthem MediBlue Value Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,741.20 |
Browse Plan Formulary |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | None | $1,588.20 |
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 |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
All Generics, All Brands |
2 |
Tier 2 |
0% | 0% | None | $1,588.20 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,759.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,759.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Inter Valley Health Plan Service To Seniors (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,744.80 |
Browse Plan Formulary select insulin pay $11-$35 copay but not this drug |
L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | None | $1,830.60 |
Browse Plan Formulary |
L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
All Generics, All Brands |
2 |
Tier 2 |
0% | 0% | None | $1,830.60 |
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 |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | None | $1,588.20 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
All Generics, All Brands |
2 |
Tier 2 |
0% | 0% | None | $1,588.20 |
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 | None | $1,588.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 |
No |
5 |
Specialty Tier |
31% | n/a | None | $1,588.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Molina Medicare Choice Care Select (HMO)
|
$0.00 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | None | $1,588.20 |
Browse Plan Formulary |
Molina Medicare Choice Care Select (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $1,588.20 |
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 |
Molina Medicare Complete Care (HMO D-SNP)
|
$0.00 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | None | $1,588.20 |
Browse Plan Formulary |
SCAN Balance (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,588.20 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
SCAN Balance (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
5 |
Specialty Tier |
33% | n/a | None | $1,588.20 |
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. |
5 |
Specialty Tier |
33% | n/a | None | $1,588.20 |
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. |
5 |
Specialty Tier |
33% | n/a | None | $1,588.20 |
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. |
5 |
Specialty Tier |
25% | n/a | None | $1,585.20 |
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 |
SCAN Connections at Home (HMO D-SNP)
|
$0.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | None | $1,585.20 |
Browse Plan Formulary |
SCAN Embrace (HMO I-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,588.20 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
SCAN Embrace (HMO I-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
5 |
Specialty Tier |
33% | n/a | None | $1,588.20 |
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. |
5 |
Specialty Tier |
33% | n/a | None | $1,585.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SCAN Healthy at Home (HMO I-SNP)
|
$0.00 |
$0 |
Some Generics |
5 |
Specialty Tier |
33% | n/a | None | $1,585.80 |
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. |
5 |
Specialty Tier |
33% | n/a | None | $1,588.20 |
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 |
SCAN Venture (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,588.20 |
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. |
5 |
Specialty Tier |
33% | n/a | None | $1,588.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Chronic Complete (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,725.60 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
UnitedHealthcare Chronic Complete (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,725.60 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
Wellcare Dual Liberty (HMO D-SNP)
|
$0.00 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | None | $1,705.20 |
Browse Plan Formulary |
Wellcare Dual Liberty Freedom (HMO D-SNP)
|
$0.00 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | None | $1,695.60 |
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 |
Wellcare Dual Liberty Freedom (HMO D-SNP)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $1,695.60 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,718.40 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,718.40 |
Browse Plan Formulary |
Wellcare Giveback Focus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,698.60 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Wellcare Giveback Focus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,698.60 |
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. |
5 |
Specialty Tier |
33% | n/a | None | $1,718.40 |
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 No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,707.00 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,707.00 |
Browse Plan Formulary |
Wellcare No Premium Best (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,707.00 |
Browse Plan Formulary |
Wellcare No Premium Best (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,707.00 |
Browse Plan Formulary |
Wellcare Plus (HMO)
|
$0.00 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | None | $1,714.20 |
Browse Plan Formulary |
Wellcare Plus (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $1,714.20 |
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 Specialty No Premium (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | None | $1,707.00 |
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 |
5 |
Specialty Tier |
33% | n/a | None | $1,707.00 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Anthem MediBlue Coordination Plus (HMO)
|
$2.10 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | Q:120 /30Days | $1,741.20 |
Browse Plan Formulary |
Anthem MediBlue Coordination Plus (HMO)
|
$2.10 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | Q:120 /30Days | $1,741.20 |
Browse Plan Formulary |
Wellcare Low Premium (HMO)
|
$18.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,718.40 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$21.50 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | Q:120 /30Days | $1,741.20 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Anthem MediBlue Connect Plus (HMO)
|
$21.50 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | Q:120 /30Days | $1,741.20 |
Browse Plan Formulary |
Anthem MediBlue Connect (HMO D-SNP)
|
$22.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | Q:120 /30Days | $1,733.40 |
Browse Plan Formulary |
Anthem MediBlue Connect (HMO D-SNP)
|
$22.00 |
$480 |
Many Generics, Some Brands |
5 |
Specialty Tier |
25% | n/a | Q:120 /30Days | $1,733.40 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$22.60 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | Q:120 /30Days | $1,758.60 |
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 | Q:120 /30Days | $1,758.60 |
Browse Plan Formulary |
SCAN Prime (HMO)
|
$25.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,588.20 |
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 |
Anthem MediBlue Extra (HMO)
|
$25.70 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | Q:120 /30Days | $1,745.40 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$25.70 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | Q:120 /30Days | $1,745.40 |
Browse Plan Formulary |
Align Premier (HMO I-SNP)
|
$26.70 |
$480 |
No |
1 |
Tier 1 |
25% | 25% | None | $1,747.20 |
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% | None | $1,747.20 |
Browse Plan Formulary |
AARP Medicare Advantage SecureHorizons Premier (HMO)
|
$29.70 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,725.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage SecureHorizons Premier (HMO)
|
$29.70 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:120 /30Days | $1,725.60 |
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 |
UnitedHealthcare Medicare Advantage Assure (HMO)
|
$32.70 |
$480 |
No |
5 |
Tier 5 |
25% | 25% | Q:120 /30Days | $1,735.80 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Assure (HMO)
|
$32.70 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | Q:120 /30Days | $1,735.80 |
Browse Plan Formulary |
Inter Valley Health Plan Vitality Plus (HMO)
|
$33.20 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | Q:120 /30Days | $1,744.80 |
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 | None | $1,588.20 |
Browse Plan Formulary |
SCAN Connections (HMO D-SNP)
|
$33.20 |
$480 |
Some Generics |
5 |
Specialty Tier |
25% | n/a | None | $1,585.20 |
Browse Plan Formulary |
SCAN Connections at Home (HMO D-SNP)
|
$33.20 |
$480 |
Some Generics |
5 |
Specialty Tier |
25% | n/a | None | $1,585.20 |
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 |
SCAN Plus (HMO)
|
$33.20 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $1,590.60 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$33.20 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | None | $1,590.60 |
Browse Plan Formulary |
VillageHealth (HMO-POS C-SNP)
|
$33.20 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | None | $1,588.20 |
Browse Plan Formulary |
VillageHealth (HMO-POS C-SNP)
|
$33.20 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $1,588.20 |
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 | None | $1,705.20 |
Browse Plan Formulary |
Wellcare Plus Sapphire I (HMO)
|
$33.20 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | None | $1,705.80 |
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 |
Wellcare Plus Sapphire I (HMO)
|
$33.20 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $1,705.80 |
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 | None | $1,704.60 |
Browse Plan Formulary |
Wellcare Plus Sapphire II (HMO)
|
$33.20 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | None | $1,704.60 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$48.50 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,764.00 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$90.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | None | $1,764.00 |
Browse Plan Formulary |