INDOMETHACIN ER 75 MG CAPSULE ER [Indocin SR] (30 CAPSULES ) (NDC: 31722056560)
2023 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 |
Align Connect (HMO C-SNP)
|
$0.00 |
$505* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$2.00 | $6.00 | None | $15.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Align Connect (HMO C-SNP)
|
$0.00 |
$505* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$2.00 | $6.00 | None | $15.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Align Thrive (HMO I-SNP)
|
$0.00 |
$505* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$2.00 | $6.00 | None | $15.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Align Thrive (HMO I-SNP)
|
$0.00 |
$505* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$2.00 | $6.00 | None | $15.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health AVA (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days | $22.27 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 |
Alignment Health AVA (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days | $22.27 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health AVA (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days | $22.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health AVA (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days | $22.69 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health CalPlus + Veterans (HMO)
|
$0.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $21.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health CalPlus + Veterans (HMO)
|
$0.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | 25% | Q:60 /30Days | $21.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health ESRD Balance (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days | $22.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
|
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 |
Alignment Health ESRD Balance (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days | $22.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health Harmony (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days | $22.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health Harmony (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days | $22.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health Heart & Diabetes (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | $75.00 | Q:60 /30Days | $21.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health Heart & Diabetes (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | $75.00 | Q:60 /30Days | $21.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health My Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | $75.00 | Q:60 /30Days | $22.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 |
Alignment Health My Choice (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | $75.00 | Q:60 /30Days | $22.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health My Choice CalPlus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days | $21.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health My Choice CalPlus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days | $21.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health Platinum (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | $75.00 | Q:60 /30Days | $22.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health Platinum (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | $75.00 | Q:60 /30Days | $22.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health smartHMO (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | $75.00 | Q:60 /30Days | $21.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 |
Alignment Health smartHMO (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$30.00 | $75.00 | Q:60 /30Days | $21.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health the ONE + Rite Aid (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days | $21.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Alignment Health the ONE + Rite Aid (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:60 /30Days | $21.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Care On Site (HMO I-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | P | $11.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Care On Site (HMO I-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | P | $11.68 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Diabetes Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | P | $29.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | P | $29.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Dual Advantage (HMO D-SNP)
|
$0.00 |
$380 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $28.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Dual Advantage (HMO D-SNP)
|
$0.00 |
$380 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $28.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue ESRD Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | P | $29.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue ESRD Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | P | $29.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Full Dual Advantage (HMO D-SNP)
|
$0.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $28.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 Full Dual Advantage (HMO D-SNP)
|
$0.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $28.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Heart Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | P | $29.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Heart Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | P | $29.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Lung Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | P | $29.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Lung Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | P | $29.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P | $29.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P | $29.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P | $29.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | P | $29.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue StartSmart Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$14.50 | $0.00 | P | $29.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue StartSmart Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$14.50 | $0.00 | P | $29.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Value Plus (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | P | $29.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 Value Plus (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | P | $29.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $95.00 | None | $15.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$38.00 | $95.00 | None | $15.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Shield 65 Plus Plan 2 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | None | $11.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Shield 65 Plus Plan 2 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$40.00 | $100.00 | None | $11.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Shield Balance (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | $87.50 | None | $18.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 Balance (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | $87.50 | None | $18.12 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Shield Inspire (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | $87.50 | None | $15.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Shield Inspire (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | $87.50 | None | $15.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Fortune Medicare Advantage (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:60 /30Days | $9.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Fortune Medicare Advantage (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:60 /30Days | $10.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Fortune Medicare Advantage (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:60 /30Days | $10.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Clever Care Fortune Medicare Advantage (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:60 /30Days | $9.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Fortune Medicare Advantage (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:60 /30Days | $9.51 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:60 /30Days | $9.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:60 /30Days | $10.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:60 /30Days | $10.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:60 /30Days | $9.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
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, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | Q:60 /30Days | $9.51 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Value Medicare Advantage (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$10.00 | $20.00 | Q:60 /30Days | $9.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Value Medicare Advantage (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$10.00 | $20.00 | Q:60 /30Days | $10.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Value Medicare Advantage (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$10.00 | $20.00 | Q:60 /30Days | $10.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Value Medicare Advantage (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$10.00 | $20.00 | Q:60 /30Days | $9.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Value Medicare Advantage (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$10.00 | $20.00 | Q:60 /30Days | $9.51 |
Browse Plan Formulary all covered insulin pay $35 or less |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $16.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $16.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H5619-146 (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $16.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H5619-146 (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $16.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
Imperial Dynamic Plan (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$3.00 | $5.00 | None | $18.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Imperial Dynamic Plan (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$3.00 | $5.00 | None | $18.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Imperial Senior Value (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $10.00 | None | $18.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Imperial Senior Value (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $10.00 | None | $18.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Imperial Strong (HMO)
|
$0.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $18.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Imperial Strong (HMO)
|
$0.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $18.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Imperial Traditional (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $10.00 | None | $18.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Imperial Traditional (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $10.00 | None | $18.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$3.00 | $6.00 | None | $21.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$3.00 | $6.00 | None | $21.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Kaiser Permanente Sr Advantage LA, Orange Value (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$3.00 | $6.00 | None | $21.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Kaiser Permanente Sr Advantage LA, Orange Value (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$3.00 | $6.00 | None | $21.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
PHP (HMO C-SNP)
|
$0.00 |
$505 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic |
15% | n/a | P Q:60 /30Days | $9.51 |
Browse Plan Formulary all covered insulin pay $35 or less |
PHP (HMO C-SNP)
|
$0.00 |
$505 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic |
15% | n/a | P Q:60 /30Days | $9.51 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 Affirm partnered with Included LGBTQ+ Health (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $5.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Affirm partnered with Included LGBTQ+ Health (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $5.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Balance (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $4.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Balance (HMO C-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $4.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Classic (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $5.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Classic (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $5.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Plan Name |
Monthly Prem. |
De- duct- ible |
Additional Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SCAN Embrace (HMO I-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $5.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Embrace (HMO I-SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $5.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Healthy at Home (HMO I-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | None | $4.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Healthy at Home (HMO I-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | None | $4.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Venture (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | None | $4.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Venture (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | None | $4.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
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)
|
$9.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $60.00 | P | $28.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Connect (HMO D-SNP)
|
$9.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $60.00 | P | $28.54 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Extra (HMO)
|
$23.00 |
$505 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $29.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem MediBlue Extra (HMO)
|
$23.00 |
$505 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $29.59 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H5619-149 (HMO)
|
$24.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $0.00 | None | $16.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H5619-149 (HMO)
|
$24.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$5.00 | $0.00 | None | $16.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
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)
|
$25.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $5.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Prime (HMO)
|
$25.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $5.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Advantage Medicare Medi-Cal Los Angeles (HMO D-SNP)
|
$29.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $21.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Advantage Medicare Medi-Cal Los Angeles (HMO D-SNP)
|
$29.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $21.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
VillageHealth (HMO-POS C-SNP)
|
$31.20 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | None | $5.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
VillageHealth (HMO-POS C-SNP)
|
$31.20 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | None | $5.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 Jasmine Medicare Advantage (HMO C-SNP)
|
$31.80 |
$505 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
25% | 25% | Q:60 /30Days | $9.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Jasmine Medicare Advantage (HMO C-SNP)
|
$31.80 |
$505 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
25% | 25% | Q:60 /30Days | $10.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Jasmine Medicare Advantage (HMO C-SNP)
|
$31.80 |
$505 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
25% | 25% | Q:60 /30Days | $9.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clever Care Jasmine Medicare Advantage (HMO C-SNP)
|
$31.80 |
$505 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
25% | 25% | Q:60 /30Days | $9.51 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Connections at Home (HMO D-SNP)
|
$37.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $4.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Connections at Home (HMO D-SNP)
|
$37.60 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $4.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
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)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $15.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Align Premier (HMO I-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $15.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Connections (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $4.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
SCAN Connections (HMO D-SNP)
|
$38.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $4.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Shield Enhanced (HMO)
|
$39.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | $87.50 | None | $15.82 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Shield Enhanced (HMO)
|
$39.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$35.00 | $87.50 | None | $15.82 |
Browse Plan Formulary all covered insulin pay $35 or less |