STELARA 45 MG/0.5 ML SYRINGE (0.5ML ) (NDC: 57894006003)
2022 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
See your cost using a drug discount card: Compare prices at pharmacies near you |
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 | P Q:3 /84Days | $26,899.15 |
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 | P Q:3 /84Days | $26,899.15 |
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 | P Q:3 /84Days | $26,899.15 |
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 | P Q:3 /84Days | $26,899.15 |
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 | P Q:3 /84Days | $26,899.15 |
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 | P Q:3 /84Days | $26,899.15 |
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 | P Q:3 /84Days | $26,899.15 |
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 | P Q:3 /84Days | $26,899.15 |
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:1 /28Days | $27,536.89 |
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 | P Q:1 /28Days | $27,536.89 |
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 | P Q:1 /28Days | $27,536.89 |
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 | P Q:1 /28Days | $27,536.89 |
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:1 /28Days | $27,536.89 |
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:1 /28Days | $27,536.89 |
Browse Plan Formulary |
Align Connect (HMO C-SNP)
|
$0.00 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:1 /28Days | $27,409.67 |
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 Q:1 /28Days | $27,409.67 |
Browse Plan Formulary |
Align Thrive (HMO I-SNP)
|
$0.00 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:1 /28Days | $27,409.67 |
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 | P Q:1 /28Days | $27,409.67 |
Browse Plan Formulary |
Anthem Blue Cross Cal MediConnect (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | P Q:1 /28Days | $24,510.26 |
Browse Plan Formulary |
Anthem Blue Cross Cal MediConnect (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
All Generics, All Brands |
2 |
Tier 2 |
0% | 0% | P Q:1 /28Days | $24,510.26 |
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 | P Q:1 /28Days | $24,502.41 |
Browse Plan Formulary |
Anthem MediBlue Care On Site (HMO I-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $24,502.41 |
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 | P Q:1 /28Days | $27,653.21 |
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 | P Q:1 /28Days | $27,653.21 |
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 | P Q:1 /28Days | $27,667.85 |
Browse Plan Formulary |
Anthem MediBlue Dual Advantage (HMO D-SNP)
|
$0.00 |
$480 |
Few Generics |
5 |
Specialty Tier |
25% | n/a | P Q:1 /28Days | $27,667.85 |
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 | P Q:1 /28Days | $27,653.21 |
Browse Plan Formulary |
Anthem MediBlue ESRD Care (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $27,653.21 |
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 | P Q:1 /28Days | $27,653.21 |
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 | P Q:1 /28Days | $27,653.21 |
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 | P Q:1 /28Days | $27,653.21 |
Browse Plan Formulary |
Anthem MediBlue Lung Care (HMO C-SNP)
|
$0.00 |
$0 |
Many Generics, Some Brands |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $27,653.21 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $27,653.21 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $27,653.21 |
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:1 /28Days | $27,653.21 |
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 | P Q:1 /28Days | $27,653.21 |
Browse Plan Formulary |
Anthem MediBlue StartSmart Plus (HMO)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $27,659.42 |
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 | P Q:1 /28Days | $27,659.42 |
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 | P Q:1 /28Days | $27,653.21 |
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 | P Q:1 /28Days | $27,653.21 |
Browse Plan Formulary |
AVA (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $25,826.57 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
AVA (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $25,826.57 |
Browse Plan Formulary |
AVA (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $25,826.13 |
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 | $24,730.27 |
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 | $24,730.27 |
Browse Plan Formulary |
Blue Shield 65 Plus Plan 2 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $24,730.54 |
Browse Plan Formulary |
Blue Shield 65 Plus Plan 2 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $24,730.54 |
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 AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $24,730.27 |
Browse Plan Formulary |
Blue Shield AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $24,730.27 |
Browse Plan Formulary |
Blue Shield Balance (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $24,738.76 |
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. |
5 |
Specialty Tier |
33% | n/a | P | $24,738.76 |
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. |
5 |
Specialty Tier |
33% | n/a | P | $24,730.27 |
Browse Plan Formulary |
Blue Shield Inspire (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $24,730.27 |
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 Promise Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
3 |
Tier 3 |
0% | 0% | P | $24,794.39 |
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 | $24,794.39 |
Browse Plan Formulary |
Blue Shield TotalDual Plan (HMO D-SNP)
|
$0.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $24,796.05 |
Browse Plan Formulary |
Blue Shield Vital (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $24,679.94 |
Browse Plan Formulary |
Blue Shield Vital (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $24,679.94 |
Browse Plan Formulary |
Brand New Day Bridges Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $24,752.60 |
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 Bridges Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics |
5 |
Specialty Tier |
33% | n/a | P | $24,752.60 |
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 | $24,752.60 |
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 | $24,752.60 |
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 | $24,752.60 |
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 | $24,752.60 |
Browse Plan Formulary |
Brand New Day Dual Access Plan (HMO D-SNP)
|
$0.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $24,752.60 |
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 Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $24,752.60 |
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 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $24,752.60 |
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 |
5 |
Specialty Tier |
33% | n/a | P | $24,752.60 |
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 |
5 |
Specialty Tier |
33% | n/a | P | $24,752.60 |
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 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
30% | n/a | P | $24,752.60 |
Browse Plan Formulary |
Brand New Day Harmony Care Plan (HMO C-SNP)
|
$0.00 |
$100 |
Some Generics |
5 |
Specialty Tier |
30% | n/a | P | $24,752.60 |
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 Part B Savings Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $24,752.60 |
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 | $24,752.60 |
Browse Plan Formulary |
Brand New Day Select Care I Plan (HMO I-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $24,752.60 |
Browse Plan Formulary |
Brand New Day Select Care I Plan (HMO I-SNP)
|
$0.00 |
$0 |
Some Generics |
5 |
Specialty Tier |
25% | n/a | P | $24,752.60 |
Browse Plan Formulary |
CalPlus (HMO)
|
$0.00 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | P | $25,777.19 |
Browse Plan Formulary |
CalPlus (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $25,777.19 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Central Health Focus Plan (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $24,752.60 |
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 |
5 |
Specialty Tier |
33% | n/a | P | $24,752.60 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Central Health Medi-Medi Plan (HMO D-SNP)
|
$0.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $24,752.60 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $24,752.60 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $24,752.60 |
Browse Plan Formulary |
Central Health Savings Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $24,752.60 |
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 |
Central Health Savings Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $24,752.60 |
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 | $24,752.60 |
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 | $24,752.60 |
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 | $24,752.60 |
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 | $24,752.60 |
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 | $24,752.60 |
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, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | P | $24,752.60 |
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 | $24,752.60 |
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 | $24,752.60 |
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 | $24,752.60 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
ESRD Balance (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $25,840.03 |
Browse Plan Formulary |
ESRD Balance (HMO C-SNP)
|
$0.00 |
$0 |
Few Generics |
5 |
Specialty Tier |
33% | n/a | P | $25,840.03 |
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 |
No |
2 |
Tier 2 |
0% | 0% | P Q:1 /28Days | $24,794.39 |
Browse Plan Formulary |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
All Generics, All Brands |
2 |
Tier 2 |
0% | 0% | P Q:1 /28Days | $24,794.39 |
Browse Plan Formulary |
Heart & Diabetes (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $25,789.54 |
Browse Plan Formulary |
Heart & Diabetes (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics |
5 |
Specialty Tier |
33% | n/a | P | $25,789.54 |
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 | P Q:2 /84Days | $27,482.94 |
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 | P Q:2 /84Days | $27,482.94 |
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 |
Imperial Dynamic Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $25,777.48 |
Browse Plan Formulary select insulin pay $0 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 | $25,777.48 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Imperial Senior Value (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $25,783.11 |
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 | $25,783.11 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Imperial Strong (HMO)
|
$0.00 |
$480 |
No |
5 |
Tier 5 |
25% | 25% | P | $25,783.11 |
Browse Plan Formulary |
Imperial Strong (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $25,783.11 |
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 |
Imperial Traditional (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $25,783.11 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Imperial Traditional (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $25,783.11 |
Browse Plan Formulary select insulin pay $0 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 | P | $27,553.21 |
Browse Plan Formulary select insulin pay $11-$35 copay but not this drug |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | P | $16,806.00 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | P | $16,806.00 |
Browse Plan Formulary |
L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | P Q:1 /28Days | $28,766.14 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
All Generics, All Brands |
2 |
Tier 2 |
0% | 0% | P Q:1 /28Days | $28,766.14 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | P Q:1 /28Days | $24,794.39 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
All Generics, All Brands |
2 |
Tier 2 |
0% | 0% | P Q:1 /28Days | $24,794.39 |
Browse Plan Formulary |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 |
No |
5 |
Specialty Tier |
31% | n/a | P Q:1 /28Days | $24,796.13 |
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 |
5 |
Specialty Tier |
31% | n/a | P Q:1 /28Days | $24,796.13 |
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 | P Q:1 /28Days | $24,796.13 |
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 Select (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:1 /28Days | $24,796.13 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$0.00 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:1 /28Days | $24,795.71 |
Browse Plan Formulary |
My Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $25,822.01 |
Browse Plan Formulary |
My Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $25,822.01 |
Browse Plan Formulary |
PHP (HMO C-SNP)
|
$0.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
4 |
Specialty Tier |
25% | n/a | P | $24,752.60 |
Browse Plan Formulary |
PHP (HMO C-SNP)
|
$0.00 |
$480 |
Few Generics |
4 |
Specialty Tier |
25% | n/a | P | $24,752.60 |
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 |
Platinum (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $25,840.03 |
Browse Plan Formulary |
Platinum (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $25,840.03 |
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 | P | $24,536.47 |
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 | P | $24,536.47 |
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 | P | $24,530.28 |
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 | P | $24,530.28 |
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 Connections (HMO D-SNP)
|
$0.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $24,632.38 |
Browse Plan Formulary |
SCAN Connections at Home (HMO D-SNP)
|
$0.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $24,632.38 |
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 | P | $24,530.28 |
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 | P | $24,530.28 |
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 | P | $24,622.05 |
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 | P | $24,622.05 |
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 Prime (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $24,530.28 |
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 | P | $24,536.47 |
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 | P | $24,536.47 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
smartHMO (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $25,864.79 |
Browse Plan Formulary |
smartHMO (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $25,864.79 |
Browse Plan Formulary |
the ONE + Rite Aid (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $25,811.43 |
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 |
the ONE + Rite Aid (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $25,811.43 |
Browse Plan Formulary |
UnitedHealthcare Chronic Complete (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:3 /84Days | $26,899.15 |
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 | P Q:3 /84Days | $26,899.15 |
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 | P Q:1 /28Days | $26,944.40 |
Browse Plan Formulary |
Wellcare Dual Liberty Freedom (HMO D-SNP)
|
$0.00 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:1 /28Days | $26,950.29 |
Browse Plan Formulary |
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 | P Q:1 /28Days | $26,950.29 |
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 Giveback (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $27,122.25 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $27,122.25 |
Browse Plan Formulary |
Wellcare Giveback Focus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $27,158.53 |
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 | P Q:1 /28Days | $27,158.53 |
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 | P Q:1 /28Days | $27,124.35 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $27,136.25 |
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 | P Q:1 /28Days | $27,136.25 |
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 | P Q:1 /28Days | $27,136.25 |
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 | P Q:1 /28Days | $27,136.25 |
Browse Plan Formulary |
Wellcare Plus (HMO)
|
$0.00 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:1 /28Days | $26,943.67 |
Browse Plan Formulary |
Wellcare Plus (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:1 /28Days | $26,943.67 |
Browse Plan Formulary |
Wellcare Specialty No Premium (HMO C-SNP)
|
$0.00 |
$0 |
No |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $27,135.42 |
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 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 Q:1 /28Days | $27,135.42 |
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 | P Q:1 /28Days | $27,653.21 |
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 | P Q:1 /28Days | $27,653.21 |
Browse Plan Formulary |
Wellcare Low Premium (HMO)
|
$18.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:1 /28Days | $27,124.35 |
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 | P Q:1 /28Days | $27,660.65 |
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 | P Q:1 /28Days | $27,660.65 |
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 (HMO D-SNP)
|
$22.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P Q:1 /28Days | $27,669.21 |
Browse Plan Formulary |
Anthem MediBlue Connect (HMO D-SNP)
|
$22.00 |
$480 |
Many Generics, Some Brands |
5 |
Specialty Tier |
25% | n/a | P Q:1 /28Days | $27,669.21 |
Browse Plan Formulary |
AVA (PPO)
|
$22.50 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $25,826.13 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$22.60 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:2 /84Days | $27,469.99 |
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:2 /84Days | $27,469.99 |
Browse Plan Formulary |
SCAN Prime (HMO)
|
$25.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $24,530.28 |
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 | P Q:1 /28Days | $27,658.97 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$25.70 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P Q:1 /28Days | $27,658.97 |
Browse Plan Formulary |
Align Premier (HMO I-SNP)
|
$26.70 |
$480 |
No |
1 |
Tier 1 |
25% | 25% | P Q:1 /28Days | $27,409.67 |
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% | P Q:1 /28Days | $27,409.67 |
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% | P | $16,632.71 |
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% | P | $16,632.71 |
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 Premier (HMO)
|
$29.70 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:3 /84Days | $26,899.15 |
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 | P Q:3 /84Days | $26,899.15 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Kaiser Permanente Sr Adv Medicare Medi-Cal (HMO D-SNP)
|
$31.40 |
$480 |
No |
5 |
Tier 5 |
15% | 15% | P | $18,430.17 |
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% | P | $18,430.17 |
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 | $24,752.60 |
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 | $24,752.60 |
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 |
UnitedHealthcare Medicare Advantage Assure (HMO)
|
$32.70 |
$480 |
No |
5 |
Tier 5 |
25% | 25% | P Q:3 /84Days | $26,779.81 |
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% | P Q:3 /84Days | $26,779.81 |
Browse Plan Formulary |
Brand New Day Dual Access Plan (HMO D-SNP)
|
$32.90 |
$480 |
Some Generics |
5 |
Specialty Tier |
25% | n/a | P | $24,752.60 |
Browse Plan Formulary |
Blue Shield Coordinated Choice Plan (HMO)
|
$33.20 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $24,796.54 |
Browse Plan Formulary |
Blue Shield Coordinated Choice Plan (HMO)
|
$33.20 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $24,796.54 |
Browse Plan Formulary |
Blue Shield TotalDual Plan (HMO D-SNP)
|
$33.20 |
$480 |
Few Generics |
5 |
Specialty Tier |
25% | n/a | P | $24,796.05 |
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 Choice Plan (HMO C-SNP)
|
$33.20 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $24,752.60 |
Browse Plan Formulary |
Brand New Day Bridges Choice Plan (HMO C-SNP)
|
$33.20 |
$480 |
Some Generics |
5 |
Specialty Tier |
25% | n/a | P | $24,752.60 |
Browse Plan Formulary |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$33.20 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $24,752.60 |
Browse Plan Formulary |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$33.20 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $24,752.60 |
Browse Plan Formulary |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$33.20 |
$480 |
Some Generics |
5 |
Specialty Tier |
25% | n/a | P | $24,752.60 |
Browse Plan Formulary |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$33.20 |
$480 |
Some Generics |
5 |
Specialty Tier |
25% | n/a | P | $24,752.60 |
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 Harmony Choice Plan (HMO C-SNP)
|
$33.20 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $24,752.60 |
Browse Plan Formulary |
Brand New Day Harmony Choice Plan (HMO C-SNP)
|
$33.20 |
$480 |
Some Generics |
5 |
Specialty Tier |
25% | n/a | P | $24,752.60 |
Browse Plan Formulary |
Brand New Day Select Choice I Plan (HMO I-SNP)
|
$33.20 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $24,752.60 |
Browse Plan Formulary |
Brand New Day Select Choice I Plan (HMO I-SNP)
|
$33.20 |
$480 |
Some Generics |
5 |
Specialty Tier |
25% | n/a | P | $24,752.60 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO D-SNP)
|
$33.20 |
$480 |
Many Generics, Some Brands |
5 |
Specialty Tier |
25% | n/a | P | $24,752.60 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$33.20 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $24,752.60 |
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 |
Central Health Premier Plan (HMO)
|
$33.20 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $24,752.60 |
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 | $24,752.60 |
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 | $24,752.60 |
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 | $24,752.60 |
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 | $25,783.11 |
Browse Plan Formulary |
Imperial Traditional Plus (HMO)
|
$33.20 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $25,783.11 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Inter Valley Health Plan Vitality Plus (HMO)
|
$33.20 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $27,553.21 |
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 Q:1 /28Days | $24,795.71 |
Browse Plan Formulary |
SCAN Connections (HMO D-SNP)
|
$33.20 |
$480 |
Some Generics |
5 |
Specialty Tier |
25% | n/a | P | $24,632.38 |
Browse Plan Formulary |
SCAN Connections at Home (HMO D-SNP)
|
$33.20 |
$480 |
Some Generics |
5 |
Specialty Tier |
25% | n/a | P | $24,632.38 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$33.20 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | P | $24,622.40 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$33.20 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P | $24,622.40 |
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 |
VillageHealth (HMO-POS C-SNP)
|
$33.20 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | P | $24,530.28 |
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 | P | $24,530.28 |
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 Q:1 /28Days | $26,944.40 |
Browse Plan Formulary |
Wellcare Plus Sapphire I (HMO)
|
$33.20 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:1 /28Days | $26,942.33 |
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 Q:1 /28Days | $26,942.33 |
Browse Plan Formulary |
Wellcare Plus Sapphire II (HMO)
|
$33.20 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:1 /28Days | $26,944.27 |
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 |
5 |
Specialty Tier |
25% | n/a | P Q:1 /28Days | $26,944.27 |
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 | P Q:1 /28Days | $27,536.89 |
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 | P Q:1 /28Days | $27,536.89 |
Browse Plan Formulary |