AARP Medicare Advantage Freedom Plus (HMO-POS) - H0543-210-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $1,000 Browse Formulary |
|
|
|
|
AARP Medicare Advantage Freedom Plus (HMO-POS) - H0543-210-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $1,000 Browse Formulary |
|
|
|
|
AARP Medicare Advantage Patriot (HMO) - H0543-121-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,900 |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
AARP Medicare Advantage Patriot (HMO) - H0543-121-0
Benefit Details
|
Los Angeles |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,900 |
|
|
|
|
AARP Medicare Advantage SecureHorizons Focus (HMO) - H0543-168-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $1,000 Browse Formulary |
|
|
|
|
AARP Medicare Advantage SecureHorizons Focus (HMO) - H0543-168-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $1,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
AARP Medicare Advantage SecureHorizons Plan 1 (HMO) - H0543-001-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,400 Browse Formulary |
|
|
|
|
AARP Medicare Advantage SecureHorizons Plan 1 (HMO) - H0543-001-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,400 Browse Formulary |
|
|
|
|
AARP Medicare Advantage SecureHorizons Plan 2 (HMO) - H0543-151-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $1,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
AARP Medicare Advantage SecureHorizons Plan 2 (HMO) - H0543-151-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $1,000 Browse Formulary |
|
|
|
|
Aetna Medicare Eagle Plan (HMO) - H4982-013-0
Benefit Details
|
Los Angeles |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,200 |
new |
new |
new |
|
Aetna Medicare Eagle Plan (HMO) - H4982-013-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,200 |
new |
new |
new |
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Aetna Medicare Plus Plan (HMO) - H4982-001-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $37.00 Non-Preferred Drug: $99.00 Specialty Tier: 33%
| $999 Browse Formulary |
new |
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare Plus Plan (HMO) - H4982-001-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $37.00 Non-Preferred Drug: $99.00 Specialty Tier: 33%
| $999 Browse Formulary |
new |
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare Prime Plan (HMO) - H0523-061-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $2,200 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Aetna Medicare Prime Plan (HMO) - H0523-061-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $2,200 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare Select Plan (HMO) - H0523-002-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $2,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare Select Plan (HMO) - H0523-002-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $2,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Anthem Blue Cross Cal MediConnect (Medicare-Medicaid Plan) - H6229-005-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
All Generics, All Brands | Tier 1: 0% Tier 2: 0% Tier 3: 0% Tier 4: 0%
| n/a Browse Formulary |
-- |
-- |
-- |
|
Anthem MediBlue Care On Site (HMO I-SNP) - H0544-005-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.50 Preferred Brand: $37.50 Non-Preferred Drug: $85.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
|
Anthem MediBlue Care On Site (HMO I-SNP) - H0544-005-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.50 Preferred Brand: $37.50 Non-Preferred Drug: $85.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Anthem MediBlue Diabetes Care (HMO C-SNP) - H0544-004-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.50 Preferred Brand: $37.50 Non-Preferred Drug: $85.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
|
Anthem MediBlue Diabetes Care (HMO C-SNP) - H0544-004-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.50 Preferred Brand: $37.50 Non-Preferred Drug: $85.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
|
Anthem MediBlue ESRD Care (HMO C-SNP) - H0544-015-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.50 Preferred Brand: $37.50 Non-Preferred Drug: $85.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Anthem MediBlue ESRD Care (HMO C-SNP) - H0544-015-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.50 Preferred Brand: $37.50 Non-Preferred Drug: $85.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
|
Anthem MediBlue Heart Care (HMO C-SNP) - H0544-013-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.50 Preferred Brand: $37.50 Non-Preferred Drug: $85.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
|
Anthem MediBlue Heart Care (HMO C-SNP) - H0544-013-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.50 Preferred Brand: $37.50 Non-Preferred Drug: $85.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Anthem MediBlue Lung Care (HMO C-SNP) - H0544-014-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.50 Preferred Brand: $37.50 Non-Preferred Drug: $85.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
|
Anthem MediBlue Lung Care (HMO C-SNP) - H0544-014-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.50 Preferred Brand: $37.50 Non-Preferred Drug: $85.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
|
Anthem MediBlue Plus (HMO) - H0544-061-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Anthem MediBlue Plus (HMO) - H0544-061-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Select (HMO) - H0544-058-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Select (HMO) - H0544-058-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Anthem MediBlue StartSmart Plus (HMO) - H0544-007-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $5.00 Generic: $14.50 Preferred Brand: $45.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $10.00
| $3,000 Browse Formulary |
|
|
|
|
Anthem MediBlue StartSmart Plus (HMO) - H0544-007-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $5.00 Generic: $14.50 Preferred Brand: $45.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $10.00
| $3,000 Browse Formulary |
|
|
|
|
Anthem MediBlue Value Plus (HMO) - H0544-002-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.50 Preferred Brand: $37.50 Non-Preferred Drug: $85.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $900 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Anthem MediBlue Value Plus (HMO) - H0544-002-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.50 Preferred Brand: $37.50 Non-Preferred Drug: $85.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $900 Browse Formulary |
|
|
|
|
AVA (HMO) - H3815-027-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $3.00 Preferred Brand: $40.00 Non-Preferred Drug: $93.00 Specialty Tier: 33% Select Care Drugs: $3.00
| $999 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AVA (HMO) - H3815-027-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $3.00 Preferred Brand: $40.00 Non-Preferred Drug: $93.00 Specialty Tier: 33% Select Care Drugs: $3.00
| $999 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Shield 65 Plus (HMO) - H0504-015-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $38.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $999 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Shield 65 Plus (HMO) - H0504-015-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $38.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $999 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Shield 65 Plus Plan 2 (HMO) - H0504-021-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $1,899 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Shield 65 Plus Plan 2 (HMO) - H0504-021-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $1,899 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Shield AdvantageOptimum Plan (HMO) - H5928-004-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $3.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $999 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Shield AdvantageOptimum Plan (HMO) - H5928-004-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $3.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $999 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Shield Inspire (HMO) - H0504-043-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $3.00 Preferred Brand: $35.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $999 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Shield Inspire (HMO) - H0504-043-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $3.00 Preferred Brand: $35.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $999 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Shield Promise Cal MediConnect Plan (Medicare-Medicaid Plan) - H0148-002-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
All Generics, All Brands | Tier 1: 0% Tier 2: 0% Tier 3: 0% Tier 4: 0%
| n/a Browse Formulary |
-- |
-- |
-- |
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Shield Vital (HMO) - H0504-044-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Shield Vital (HMO) - H0504-044-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Brand New Day Bridges Care Plan (HMO C-SNP) - H0838-028-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $45.00 Non-Preferred Drug: $90.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Brand New Day Bridges Care Plan (HMO C-SNP) - H0838-028-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $45.00 Non-Preferred Drug: $90.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
|
Brand New Day Classic Care I Plan (HMO) - H0838-025-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $999 Browse Formulary |
|
|
|
|
Brand New Day Classic Care I Plan (HMO) - H0838-025-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $999 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Brand New Day Classic Care II Plan (HMO) - H0838-037-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$50 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
| $999 Browse Formulary |
|
|
|
|
Brand New Day Classic Care II Plan (HMO) - H0838-037-0
Benefit Details
|
Los Angeles |
$0.00 |
$50 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
| $999 Browse Formulary |
|
|
|
|
Brand New Day Embrace Care Plan (HMO C-SNP) - H0838-039-1
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $90.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $9-$20 copay | n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Brand New Day Embrace Care Plan (HMO C-SNP) - H0838-039-1
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $90.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $9-$20 copay | n/a Browse Formulary |
|
|
|
|
Brand New Day Harmony Care Plan (HMO C-SNP) - H0838-032-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$100 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 30% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
|
Brand New Day Harmony Care Plan (HMO C-SNP) - H0838-032-0
Benefit Details
|
Los Angeles |
$0.00 |
$100 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 30% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Brand New Day Select Care I Plan (HMO I-SNP) - H0838-042-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $90.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
|
Brand New Day Select Care I Plan (HMO I-SNP) - H0838-042-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $90.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
|
Brandman Health Plan (Arise) (HMO C-SNP) - H7594-001-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $90.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $35 copay | n/a Browse Formulary |
new |
new |
new |
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Brandman Health Plan (Aspire) (HMO C-SNP) - H7594-003-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $45.00 Non-Preferred Drug: $90.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $35 copay | n/a Browse Formulary |
new |
new |
new |
|
Central Health Focus Plan (HMO C-SNP) - H5649-006-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $35.00 Non-Preferred Drug: $75.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
|
Central Health Focus Plan (HMO C-SNP) - H5649-006-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $35.00 Non-Preferred Drug: $75.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Central Health Medicare Plan (HMO) - H5649-001-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $35.00 Non-Preferred Drug: $75.00 Specialty Tier: 33% Select Care Drugs: $10.00
| $1,800 Browse Formulary |
|
-- |
|
|
Central Health Medicare Plan (HMO) - H5649-001-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $35.00 Non-Preferred Drug: $75.00 Specialty Tier: 33% Select Care Drugs: $10.00
| $1,800 Browse Formulary |
|
-- |
|
|
Clever Care Longevity Medicare Advantage (HMO) - H7607-002-1
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: 0% Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Brand: $75.00 Specialty Tier: 33% Supplemental Drugs: $10.00
select insulin pay $5-$35 copay | $2,999 Browse Formulary |
new |
new |
new |
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Connected Care (HMO) - H2241-012-0
Sanctioned Plan
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
select insulin pay $10-$35 copay | $1,499 Browse Formulary |
|
|
|
|
Connected Care Select (HMO C-SNP) - H2241-018-0
Sanctioned Plan
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $0 copay | n/a Browse Formulary |
|
|
|
|
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) - H3237-001-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
All Generics, All Brands | Tier 1: 0% Tier 2: 0% Tier 3: 0%
| n/a Browse Formulary |
-- |
-- |
-- |
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Health Net Gold Select (HMO) - H0562-125-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $1.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $850 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Net Gold Select (HMO) - H0562-125-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $1.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $850 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Net Green (HMO) - H0562-044-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,400 |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Health Net Green (HMO) - H0562-044-0
Benefit Details
|
Los Angeles |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,400 |
|
|
|
|
Health Net Jade (HMO C-SNP) - H0562-092-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Net Jade (HMO C-SNP) - H0562-092-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Heart & Diabetes (HMO C-SNP) - H3815-010-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $30.00 Non-Preferred Drug: $75.00 Specialty Tier: 33% Select Care Drugs: $5.00
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Heart & Diabetes (HMO C-SNP) - H3815-010-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $30.00 Non-Preferred Drug: $75.00 Specialty Tier: 33% Select Care Drugs: $5.00
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Humana Gold Plus H5619-021 (HMO) - H5619-021-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $35.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $1,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Humana Gold Plus H5619-021 (HMO) - H5619-021-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $35.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $1,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Humana Honor (HMO) - H5619-120-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $6,700 |
|
|
|
|
Humana Honor (HMO) - H5619-120-0
Benefit Details
|
Los Angeles |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $6,700 |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Imperial Dynamic Plan (HMO) - H5496-012-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $3.00 Preferred Brand: $30.00 Non-Preferred Drug: $75.00 Specialty Tier: 33%
| $899 Browse Formulary |
new |
new |
|
|
Imperial Dynamic Plan (HMO) - H5496-012-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $3.00 Preferred Brand: $30.00 Non-Preferred Drug: $75.00 Specialty Tier: 33%
| $899 Browse Formulary |
new |
new |
|
|
Imperial Senior Value (HMO C-SNP) - H5496-005-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $45.00 Non-Preferred Drug: $90.00 Specialty Tier: 33% Select Care Drugs: $3.00
select insulin pay $0 copay | n/a Browse Formulary |
new |
new |
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Imperial Senior Value (HMO C-SNP) - H5496-005-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $45.00 Non-Preferred Drug: $90.00 Specialty Tier: 33% Select Care Drugs: $3.00
select insulin pay $0 copay | n/a Browse Formulary |
new |
new |
|
|
Imperial Traditional (HMO) - H5496-007-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $45.00 Non-Preferred Drug: $90.00 Specialty Tier: 33%
| $2,999 Browse Formulary |
new |
new |
|
|
Imperial Traditional (HMO) - H5496-007-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $45.00 Non-Preferred Drug: $90.00 Specialty Tier: 33%
| $2,999 Browse Formulary |
new |
new |
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Inter Valley Health Plan Service To Seniors (HMO) - H0545-001-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $47.00 Non-Preferred Drug: 25% Specialty Tier: 33% Select Diabetic Drugs: $11.00
select insulin pay $11-$35 copay | $1,000 Browse Formulary |
|
|
|
|
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO) - H0524-003-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33% Vaccines: $0.00
| $3,400 Browse Formulary |
|
|
|
|
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO) - H0524-003-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33% Vaccines: $0.00
| $3,400 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan) - H8258-001-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
All Generics, All Brands | Tier 1: 0% Tier 2: 0% Tier 3: 0% Tier 4: 0%
| n/a Browse Formulary |
-- |
-- |
-- |
|
Molina Dual Options (Medicare-Medicaid Plan) - H8677-002-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
All Generics, All Brands | Tier 1: 0% Tier 2: 0% Tier 3: 0%
| n/a Browse Formulary |
-- |
-- |
-- |
|
My Choice (HMO) - H3815-001-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $30.00 Non-Preferred Drug: $100.00 Specialty Tier: 33% Select Care Drugs: $3.00
| $2,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
My Choice (HMO) - H3815-001-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $30.00 Non-Preferred Drug: $100.00 Specialty Tier: 33% Select Care Drugs: $3.00
| $2,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PHP (HMO C-SNP) - H5852-001-0
Benefit Details
|
Los Angeles |
$0.00 |
$445 Tier 5 exempt |
Yes, some additional gap coverage. | Generic: 15% Preferred Brand: 15% Non-Preferred Brand: 25% Specialty Tier: 25% Select Care Drugs: 0%
| n/a Browse Formulary |
-- |
-- |
|
|
PHP (HMO C-SNP) - H5852-001-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$445 Tier 5 exempt |
Yes, some additional gap coverage. | Generic: 15% Preferred Brand: 15% Non-Preferred Brand: 25% Specialty Tier: 25% Select Care Drugs: 0%
| n/a Browse Formulary |
-- |
-- |
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Platinum (HMO) - H3815-008-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $3.00 Preferred Brand: $30.00 Non-Preferred Drug: $75.00 Specialty Tier: 33% Select Care Drugs: $5.00
| $800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum (HMO) - H3815-008-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $3.00 Preferred Brand: $30.00 Non-Preferred Drug: $75.00 Specialty Tier: 33% Select Care Drugs: $5.00
| $800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
SCAN Balance (HMO C-SNP) - H5425-034-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $2.00 Preferred Brand: $30.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
select insulin pay $0 copay | n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
SCAN Balance (HMO C-SNP) - H5425-034-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $2.00 Preferred Brand: $30.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
select insulin pay $0 copay | n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
SCAN Classic (HMO) - H5425-006-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $37.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
select insulin pay $35 copay | $799 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
SCAN Classic (HMO) - H5425-006-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $37.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
select insulin pay $35 copay | $799 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
SCAN Healthy at Home (HMO I-SNP) - H9104-006-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| n/a Browse Formulary |
-- |
-- |
-- |
Higher cost-sharing at standard network pharmacies. Details:
|
SCAN Healthy at Home (HMO I-SNP) - H9104-006-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| n/a Browse Formulary |
-- |
-- |
-- |
Higher cost-sharing at standard network pharmacies. Details:
|
smartHMO (HMO) - H3815-013-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $30.00 Non-Preferred Drug: $100.00 Specialty Tier: 33% Select Care Drugs: $5.00
| $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
smartHMO (HMO) - H3815-013-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $30.00 Non-Preferred Drug: $100.00 Specialty Tier: 33% Select Care Drugs: $5.00
| $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
WellCare Best (HMO) - H5087-005-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Drug: $99.00 Specialty Tier: 33%
| $1,000 Browse Formulary |
|
-- |
|
|
WellCare Best (HMO) - H5087-005-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Drug: $99.00 Specialty Tier: 33%
| $1,000 Browse Formulary |
|
-- |
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
WellCare Dividend (HMO) - H5087-025-0
Benefit Details
|
Los Angeles |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 33%
| $2,900 Browse Formulary |
|
-- |
|
|
WellCare Dividend (HMO) - H5087-025-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 33%
| $2,900 Browse Formulary |
|
-- |
|
|
WellCare Freedom (HMO D-SNP) - H5087-001-0
Benefit Details
|
Los Angeles |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: 45% Specialty Tier: 25%
| n/a Browse Formulary |
|
-- |
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
WellCare Freedom (HMO D-SNP) - H5087-001-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: 45% Specialty Tier: 25%
| n/a Browse Formulary |
|
-- |
|
|
WellCare Plus (HMO) - H5087-017-0
Benefit Details
|
Los Angeles |
$6.70 |
$445 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: 45% Specialty Tier: 25%
| $2,500 Browse Formulary |
|
-- |
|
|
WellCare Plus (HMO) - H5087-017-0
Benefit Details
|
Los Angeles (Partial) |
$6.70 |
$445 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: 45% Specialty Tier: 25%
| $2,500 Browse Formulary |
|
-- |
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Anthem MediBlue Coordination Plus (HMO) - H0544-072-0
Benefit Details
|
Los Angeles (Partial) |
$12.20 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Coordination Plus (HMO) - H0544-072-0
Benefit Details
|
Los Angeles |
$12.20 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Net Healthy Heart (HMO) - H0562-123-0
Benefit Details
|
Los Angeles (Partial) |
$17.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $2,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Health Net Healthy Heart (HMO) - H0562-123-0
Benefit Details
|
Los Angeles |
$17.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $2,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AARP Medicare Advantage SecureHorizons Premier (HMO) - H0543-164-0
Benefit Details
|
Los Angeles (Partial) |
$19.10 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $1,000 Browse Formulary |
|
|
|
|
AARP Medicare Advantage SecureHorizons Premier (HMO) - H0543-164-0
Benefit Details
|
Los Angeles |
$19.10 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $1,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
CalPlus (HMO) - H3815-009-0
Benefit Details
|
Los Angeles |
$20.10 |
$445 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: 23% Non-Preferred Drug: 23% Specialty Tier: 25% Select Care Drugs: $5.00
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
CalPlus (HMO) - H3815-009-0
Benefit Details
|
Los Angeles (Partial) |
$20.10 |
$445 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: 23% Non-Preferred Drug: 23% Specialty Tier: 25% Select Care Drugs: $5.00
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5619-037 (HMO) - H5619-037-0
Benefit Details
|
Los Angeles |
$20.40 |
$445 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $19.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Humana Value Plus H5619-037 (HMO) - H5619-037-0
Benefit Details
|
Los Angeles (Partial) |
$20.40 |
$445 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $19.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UnitedHealthcare Medicare Advantage Assure (HMO) - H0543-153-0
Benefit Details
|
Los Angeles (Partial) |
$22.50 |
$445 |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% Tier 5: 25%
| $7,550 Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Advantage Assure (HMO) - H0543-153-0
Benefit Details
|
Los Angeles |
$22.50 |
$445 |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% Tier 5: 25%
| $7,550 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Anthem MediBlue Connect (HMO D-SNP) - H0544-003-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
|
Anthem MediBlue Connect (HMO D-SNP) - H0544-003-0
Benefit Details
|
Los Angeles |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
|
Anthem MediBlue Connect Plus (HMO) - H0544-122-1
Benefit Details
|
Los Angeles (Partial) |
$23.50 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: 25% Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25% Select Care Drugs: $0.00
| $7,550 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Anthem MediBlue Connect Plus (HMO) - H0544-122-1
Benefit Details
|
Los Angeles |
$23.50 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: 25% Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25% Select Care Drugs: $0.00
| $7,550 Browse Formulary |
|
|
|
|
SCAN Prime (HMO) - H5425-065-0
Benefit Details
|
Los Angeles |
$25.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $37.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
select insulin pay $35 copay | $699 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
SCAN Prime (HMO) - H5425-065-0
Benefit Details
|
Los Angeles (Partial) |
$25.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $37.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
select insulin pay $35 copay | $699 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Health Net Sapphire Premier (HMO) - H3561-002-0
Benefit Details
|
Los Angeles |
$25.40 |
$445 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: 45% Specialty Tier: 25%
| $3,450 Browse Formulary |
|
|
|
|
Health Net Sapphire Premier (HMO) - H3561-002-0
Benefit Details
|
Los Angeles (Partial) |
$25.40 |
$445 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: 45% Specialty Tier: 25%
| $3,450 Browse Formulary |
|
|
|
|
Health Net Amber II (HMO D-SNP) - H0562-121-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Health Net Amber II (HMO D-SNP) - H0562-121-0
Benefit Details
|
Los Angeles |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
|
|
|
|
Health Net Sapphire Premier II (HMO) - H3561-005-0
Benefit Details
|
Los Angeles |
$26.70 |
$445 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: 47% Specialty Tier: 25%
| $3,450 Browse Formulary |
|
|
|
|
Health Net Sapphire Premier II (HMO) - H3561-005-0
Benefit Details
|
Los Angeles (Partial) |
$26.70 |
$445 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: 47% Specialty Tier: 25%
| $3,450 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Health Net Amber I (HMO D-SNP) - H0562-055-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: 41% Specialty Tier: 25%
| n/a Browse Formulary |
|
|
|
|
Health Net Amber I (HMO D-SNP) - H0562-055-0
Benefit Details
|
Los Angeles |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: 41% Specialty Tier: 25%
| n/a Browse Formulary |
|
|
|
|
Health Net Sapphire (HMO) - H0562-122-0
Benefit Details
|
Los Angeles (Partial) |
$28.50 |
$445 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: 46% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,450 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Health Net Sapphire (HMO) - H0562-122-0
Benefit Details
|
Los Angeles |
$28.50 |
$445 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: 46% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,450 Browse Formulary |
|
|
|
|
Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP) - H0524-029-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 15% Tier 2: 15% Tier 3: 15% Tier 4: 15% Tier 5: 15% Tier 6: 15%
| n/a Browse Formulary |
|
|
|
|
Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP) - H0524-029-0
Benefit Details
|
Los Angeles |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 15% Tier 2: 15% Tier 3: 15% Tier 4: 15% Tier 5: 15% Tier 6: 15%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Anthem MediBlue Extra (HMO) - H0544-081-0
Benefit Details
|
Los Angeles (Partial) |
$31.50 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $2.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25%
| $900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) - H0544-081-0
Benefit Details
|
Los Angeles |
$31.50 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $2.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25%
| $900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Shield Coordinated Choice Plan (HMO) - H5928-037-0
Benefit Details
|
Los Angeles |
$31.50 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Shield Coordinated Choice Plan (HMO) - H5928-037-0
Benefit Details
|
Los Angeles (Partial) |
$31.50 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
Blue Shield TotalDual Plan (HMO D-SNP) - H5928-005-0
Benefit Details
|
Los Angeles |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25%
| n/a Browse Formulary |
|
|
|
|
Blue Shield TotalDual Plan (HMO D-SNP) - H5928-005-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Brand New Day Bridges Choice Plan (HMO C-SNP) - H0838-029-0
Benefit Details
|
Los Angeles (Partial) |
$31.50 |
$445 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: 0% Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25% Select Care Drugs: 0%
| n/a Browse Formulary |
|
|
|
|
Brand New Day Bridges Choice Plan (HMO C-SNP) - H0838-029-0
Benefit Details
|
Los Angeles |
$31.50 |
$445 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: 0% Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25% Select Care Drugs: 0%
| n/a Browse Formulary |
|
|
|
|
Brand New Day Classic Choice Plan (HMO) - H0838-033-0
Benefit Details
|
Los Angeles (Partial) |
$31.50 |
$445 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: 0% Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25% Select Care Drugs: 0%
| $7,550 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Brand New Day Classic Choice Plan (HMO) - H0838-033-0
Benefit Details
|
Los Angeles |
$31.50 |
$445 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: 0% Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25% Select Care Drugs: 0%
| $7,550 Browse Formulary |
|
|
|
|
Brand New Day Dual Access Plan (HMO D-SNP) - H0838-024-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: 0% Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25% Select Care Drugs: 0%
| n/a Browse Formulary |
|
|
|
|
Brand New Day Dual Access Plan (HMO D-SNP) - H0838-024-0
Benefit Details
|
Los Angeles |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: 0% Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25% Select Care Drugs: 0%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Brand New Day Embrace Choice Plan (HMO C-SNP) - H0838-040-1
Benefit Details
|
Los Angeles (Partial) |
$31.50 |
$445 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: 0% Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25% Select Care Drugs: 0%
| n/a Browse Formulary |
|
|
|
|
Brand New Day Embrace Choice Plan (HMO C-SNP) - H0838-040-1
Benefit Details
|
Los Angeles |
$31.50 |
$445 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: 0% Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25% Select Care Drugs: 0%
| n/a Browse Formulary |
|
|
|
|
Brand New Day Harmony Choice Plan (HMO C-SNP) - H0838-020-0
Benefit Details
|
Los Angeles (Partial) |
$31.50 |
$445 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: 0% Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25% Select Care Drugs: 0%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Brand New Day Harmony Choice Plan (HMO C-SNP) - H0838-020-0
Benefit Details
|
Los Angeles |
$31.50 |
$445 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: 0% Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25% Select Care Drugs: 0%
| n/a Browse Formulary |
|
|
|
|
Brand New Day Select Choice I Plan (HMO I-SNP) - H0838-044-0
Benefit Details
|
Los Angeles (Partial) |
$31.50 |
$445 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: 0% Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25% Select Care Drugs: 0%
| n/a Browse Formulary |
|
|
|
|
Brand New Day Select Choice I Plan (HMO I-SNP) - H0838-044-0
Benefit Details
|
Los Angeles |
$31.50 |
$445 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: 0% Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25% Select Care Drugs: 0%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Brandman Health Plan (Arise-D) (HMO C-SNP) - H7594-002-0
Benefit Details
|
Los Angeles |
$31.50 |
$445 Tier Yes exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: 0% Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25% Select Care Drugs: 0%
select insulin pay $35 copay | n/a Browse Formulary |
new |
new |
new |
|
Brandman Health Plan (Aspire-D) (HMO C-SNP) - H7594-004-0
Benefit Details
|
Los Angeles |
$31.50 |
$445 Tier Yes exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: 0% Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25% Select Care Drugs: 0%
select insulin pay $35 copay | n/a Browse Formulary |
new |
new |
new |
|
Central Health Medi-Medi Plan (HMO D-SNP) - H5649-002-0
Benefit Details
|
Los Angeles |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25% Select Care Drugs: $10.00
| n/a Browse Formulary |
|
-- |
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Central Health Medi-Medi Plan (HMO D-SNP) - H5649-002-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25% Select Care Drugs: $10.00
| n/a Browse Formulary |
|
-- |
|
|
Central Health Premier Plan (HMO) - H5649-004-0
Benefit Details
|
Los Angeles |
$31.50 |
$445 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25% Select Care Drugs: $10.00
| $6,700 Browse Formulary |
|
-- |
|
|
Central Health Premier Plan (HMO) - H5649-004-0
Benefit Details
|
Los Angeles (Partial) |
$31.50 |
$445 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25% Select Care Drugs: $10.00
| $6,700 Browse Formulary |
|
-- |
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Clever Care Balance Medicare Advantage (HMO) - H7607-003-1
Benefit Details
|
Los Angeles |
$31.50 |
$435 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: 0% Generic: 25% Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25% Supplemental Drugs: $10.00
| $7,550 Browse Formulary |
new |
new |
new |
|
Imperial Traditional Plus (HMO) - H5496-009-0
Benefit Details
|
Los Angeles |
$31.50 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: 0% Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25%
| $2,999 Browse Formulary |
new |
new |
|
|
Imperial Traditional Plus (HMO) - H5496-009-0
Benefit Details
|
Los Angeles (Partial) |
$31.50 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: 0% Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25%
| $2,999 Browse Formulary |
new |
new |
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Inter Valley Health Plan Vitality Plus (HMO) - H0545-015-0
Benefit Details
|
Los Angeles |
$31.50 |
$445 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25%
| $5,900 Browse Formulary |
|
|
|
|
Molina Medicare Complete Care (HMO D-SNP) - H5810-001-0
Benefit Details
|
Los Angeles |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $40.00 Non-Preferred Drug: 29% Specialty Tier: 25%
| n/a Browse Formulary |
|
|
|
|
Molina Medicare Complete Care (HMO D-SNP) - H5810-001-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $40.00 Non-Preferred Drug: 29% Specialty Tier: 25%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
SCAN Connections (HMO D-SNP) - H5425-010-0
Benefit Details
|
Los Angeles |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
SCAN Connections (HMO D-SNP) - H5425-010-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
SCAN Connections at Home (HMO D-SNP) - H5425-030-0
Benefit Details
|
Los Angeles |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
SCAN Connections at Home (HMO D-SNP) - H5425-030-0
Benefit Details
|
Los Angeles (Partial) |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
SCAN Plus (HMO) - H5425-045-0
Benefit Details
|
Los Angeles |
$31.50 |
$445 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
SCAN Plus (HMO) - H5425-045-0
Benefit Details
|
Los Angeles (Partial) |
$31.50 |
$445 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
VillageHealth (HMO-POS C-SNP) - H5943-002-0
Benefit Details
|
Los Angeles |
$31.50 |
$445 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25%
| n/a Browse Formulary |
|
-- |
-- |
Higher cost-sharing at standard network pharmacies. Details:
|
VillageHealth (HMO-POS C-SNP) - H5943-002-0
Benefit Details
|
Los Angeles (Partial) |
$31.50 |
$445 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25%
| n/a Browse Formulary |
|
-- |
-- |
Higher cost-sharing at standard network pharmacies. Details:
|
SCAN Classic II (HMO) - H5425-064-0
Benefit Details
|
Los Angeles |
$59.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $5,300 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
SCAN Classic II (HMO) - H5425-064-0
Benefit Details
|
Los Angeles (Partial) |
$59.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $5,300 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare Choice Plan (PPO) - H5521-125-0
Benefit Details
|
Los Angeles |
$89.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare Choice Plan (PPO) - H5521-125-0
Benefit Details
|
Los Angeles (Partial) |
$89.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|