DIMETHYL FUMARATE 30D START PK CAPSULE DR [Tecfidera] (UNITS ) (NDC: 69238162603)
2022 Medicare Prescription Drug Plan (MAPD) Information
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Plan Name |
Monthly Prem. |
De- duct- ible |
Does Plan Offer Additional Gap Coverage |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Plan’s Avg. Retail Drug Price 30-Day |
Tier Nbr. |
Tier Desc. |
30-Day Prfrd. Pharm |
90-Day Mail Order |
AARP Medicare Advantage Freedom Plus (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:120 /365Days | $967.20 |
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 /365Days | $967.20 |
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 /365Days | $967.20 |
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 /365Days | $967.20 |
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 /365Days | $967.20 |
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 |
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 /365Days | $967.20 |
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 /365Days | $967.20 |
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 /365Days | $967.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Align Connect (HMO C-SNP)
|
$0.00 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | None | $532.80 |
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 | $532.80 |
Browse Plan Formulary |
Align Thrive (HMO I-SNP)
|
$0.00 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | None | $536.40 |
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 |
Align Thrive (HMO I-SNP)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | None | $536.40 |
Browse Plan Formulary |
AVA (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,096.20 |
Browse Plan Formulary |
AVA (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,096.20 |
Browse Plan Formulary |
AVA (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,096.20 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:2 /1Days | $2,319.60 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:2 /1Days | $2,319.60 |
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 |
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 Q:2 /1Days | $2,319.60 |
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 Q:2 /1Days | $2,319.60 |
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 Q:2 /1Days | $2,319.60 |
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 Q:2 /1Days | $2,319.60 |
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 Q:2 /1Days | $2,319.60 |
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 Q:2 /1Days | $2,319.60 |
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 |
Blue Shield Inspire (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:2 /1Days | $2,319.60 |
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 Q:2 /1Days | $2,319.60 |
Browse Plan Formulary |
Blue Shield Promise Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
2 |
Tier 2 |
0% | 0% | P Q:2 /1Days | $2,320.20 |
Browse Plan Formulary |
Blue Shield Promise Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
All Generics, All Brands |
2 |
Tier 2 |
0% | 0% | P Q:2 /1Days | $2,320.20 |
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 Q:2 /1Days | $2,320.20 |
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 Q:2 /1Days | $2,319.60 |
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 |
Blue Shield Vital (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:2 /1Days | $2,319.60 |
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 | $359.40 |
Browse Plan Formulary |
Brand New Day Bridges Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics |
5 |
Specialty Tier |
33% | n/a | P | $359.40 |
Browse Plan Formulary |
Brand New Day Classic Care I Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $359.40 |
Browse Plan Formulary |
Brand New Day Classic Care I Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $359.40 |
Browse Plan Formulary |
Brand New Day Classic Care II Plan (HMO)
|
$0.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
32% | n/a | P | $359.40 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Brand New Day Classic Care II Plan (HMO)
|
$0.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
32% | n/a | P | $359.40 |
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 | $359.40 |
Browse Plan Formulary |
Brand New Day Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics |
5 |
Specialty Tier |
33% | n/a | P | $359.40 |
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 | $359.40 |
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 | $359.40 |
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 | $359.40 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Brand New Day Harmony Care Plan (HMO C-SNP)
|
$0.00 |
$100 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
30% | n/a | P | $359.40 |
Browse Plan Formulary |
Brand New Day Harmony Care Plan (HMO C-SNP)
|
$0.00 |
$100 |
Some Generics |
5 |
Specialty Tier |
30% | n/a | P | $359.40 |
Browse Plan Formulary |
Brand New Day Part B Savings Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $359.40 |
Browse Plan Formulary |
Brand New Day Part B Savings Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $359.40 |
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 | $359.40 |
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 | $359.40 |
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 |
CalPlus (HMO)
|
$0.00 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $1,096.20 |
Browse Plan Formulary |
CalPlus (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $1,096.20 |
Browse Plan Formulary |
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 | $359.40 |
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 | $359.40 |
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 | $359.40 |
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 | $359.40 |
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 |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $359.40 |
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 | $359.40 |
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 | $359.40 |
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 | $938.40 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Fortune Medicare Advantage Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | P | $938.40 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Fortune Medicare Advantage Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | P | $938.40 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | P | $938.40 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | P | $938.40 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | P | $938.40 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Value Medicare Advantage Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | P | $938.40 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Value Medicare Advantage Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | P | $938.40 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Value Medicare Advantage Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | P | $938.40 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
ESRD Balance (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,096.20 |
Browse Plan Formulary |
ESRD Balance (HMO C-SNP)
|
$0.00 |
$0 |
Few Generics |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,096.20 |
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 Q:60 /30Days | $1,096.20 |
Browse Plan Formulary |
Heart & Diabetes (HMO C-SNP)
|
$0.00 |
$0 |
Some Generics |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,096.20 |
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 | P Q:60 /30Days | $213.00 |
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:60 /30Days | $213.00 |
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 | $6,883.20 |
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 | $6,883.20 |
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 | $6,883.20 |
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 | $6,883.20 |
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 | $6,883.20 |
Browse Plan Formulary |
Imperial Strong (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $6,883.20 |
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 |
Imperial Traditional (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $6,883.20 |
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 | $6,883.20 |
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. |
4 |
Non-Preferred Drug |
25% | 25% | P | $505.20 |
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, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $10.00 | None | $5,445.60 |
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 | $5,445.60 |
Browse Plan Formulary |
L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No |
1 |
Tier 1 |
0% | 0% | None | $1,158.00 |
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 |
L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
All Generics, All Brands |
1 |
Tier 1 |
0% | 0% | None | $1,158.00 |
Browse Plan Formulary |
My Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,096.20 |
Browse Plan Formulary |
My Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,096.20 |
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 | $923.40 |
Browse Plan Formulary |
PHP (HMO C-SNP)
|
$0.00 |
$480 |
Few Generics |
4 |
Specialty Tier |
25% | n/a | P | $923.40 |
Browse Plan Formulary |
Platinum (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,096.20 |
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 |
Platinum (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,096.20 |
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 | P | $4,903.80 |
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 | $4,903.80 |
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 | $4,903.80 |
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 | $4,903.80 |
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 | P | $4,903.80 |
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 |
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 | $4,903.80 |
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 | $4,903.80 |
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 | $4,903.80 |
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 | $4,903.80 |
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 | P | $4,903.80 |
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 | P | $4,903.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SCAN Venture (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $4,903.80 |
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 | $4,903.80 |
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 Q:60 /30Days | $1,096.20 |
Browse Plan Formulary |
smartHMO (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,096.20 |
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 Q:60 /30Days | $1,096.20 |
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 Q:60 /30Days | $1,096.20 |
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 |
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 /365Days | $967.20 |
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 /365Days | $967.20 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
AVA (PPO)
|
$22.50 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,096.20 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$22.60 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $213.00 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$22.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $213.00 |
Browse Plan Formulary |
SCAN Prime (HMO)
|
$25.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P | $4,903.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Align Premier (HMO I-SNP)
|
$26.70 |
$480 |
No |
1 |
Tier 1 |
25% | 25% | None | $531.00 |
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 | $531.00 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$27.30 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Tier 2 |
$15.00 | $30.00 | None | $5,445.60 |
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 | $5,445.60 |
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 /365Days | $967.20 |
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 /365Days | $967.20 |
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 |
Kaiser Permanente Sr Adv Medicare Medi-Cal (HMO D-SNP)
|
$31.40 |
$480 |
No |
2 |
Tier 2 |
15% | 15% | None | $5,445.60 |
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 | $5,445.60 |
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 | $359.40 |
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 | $359.40 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Assure (HMO)
|
$32.70 |
$480 |
No |
5 |
Tier 5 |
25% | 25% | Q:120 /365Days | $967.20 |
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 /365Days | $967.20 |
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 |
Brand New Day Dual Access Plan (HMO D-SNP)
|
$32.90 |
$480 |
Some Generics |
5 |
Specialty Tier |
25% | n/a | P | $359.40 |
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 Q:2 /1Days | $2,320.20 |
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 Q:2 /1Days | $2,320.20 |
Browse Plan Formulary |
Blue Shield TotalDual Plan (HMO D-SNP)
|
$33.20 |
$480 |
Few Generics |
5 |
Specialty Tier |
25% | n/a | P Q:2 /1Days | $2,320.20 |
Browse Plan Formulary |
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 | $359.40 |
Browse Plan Formulary |
Brand New Day Bridges Choice Plan (HMO C-SNP)
|
$33.20 |
$480 |
Some Generics |
5 |
Specialty Tier |
25% | n/a | P | $359.40 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$33.20 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $359.40 |
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 | $359.40 |
Browse Plan Formulary |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$33.20 |
$480 |
Some Generics |
5 |
Specialty Tier |
25% | n/a | P | $359.40 |
Browse Plan Formulary |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$33.20 |
$480 |
Some Generics |
5 |
Specialty Tier |
25% | n/a | P | $359.40 |
Browse Plan Formulary |
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 | $359.40 |
Browse Plan Formulary |
Brand New Day Harmony Choice Plan (HMO C-SNP)
|
$33.20 |
$480 |
Some Generics |
5 |
Specialty Tier |
25% | n/a | P | $359.40 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Brand New Day Select Choice I Plan (HMO I-SNP)
|
$33.20 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $359.40 |
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 | $359.40 |
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 | $359.40 |
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 | $359.40 |
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 | $359.40 |
Browse Plan Formulary |
Clever Care Balance Medicare Advantage (HMO)
|
$33.20 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | 25% | P | $938.40 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Clever Care Balance Medicare Advantage (HMO)
|
$33.20 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | 25% | P | $938.40 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Balance Medicare Advantage (HMO)
|
$33.20 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | 25% | P | $938.40 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Imperial Traditional Plus (HMO)
|
$33.20 |
$480 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P | $6,883.20 |
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 | $6,883.20 |
Browse Plan Formulary |
Inter Valley Health Plan Vitality Plus (HMO)
|
$33.20 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | P | $505.20 |
Browse Plan Formulary |
SCAN Connections (HMO D-SNP)
|
$33.20 |
$480 |
Some Generics |
5 |
Specialty Tier |
25% | n/a | P | $4,903.80 |
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 |
SCAN Connections at Home (HMO D-SNP)
|
$33.20 |
$480 |
Some Generics |
5 |
Specialty Tier |
25% | n/a | P | $4,903.80 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$33.20 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | P | $4,903.80 |
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 | $4,903.80 |
Browse Plan Formulary |
VillageHealth (HMO-POS C-SNP)
|
$33.20 |
$480 |
No |
5 |
Specialty Tier |
25% | n/a | P | $4,903.80 |
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 | $4,903.80 |
Browse Plan Formulary |