CEFIXIME 100 MG/5 ML SUSPENSION [Suprax] (50.000 ML ) (NDC: 65862075150)
2022 Medicare Prescription Drug Plan (MAPD) Information
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Plan Name |
Monthly Prem. |
De- duct- ible | Does Plan Offer Additional Gap Coverage | Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Plan’s Avg. Retail Drug Price 30-Day |
Tier Nbr. |
Tier Desc. |
30-Day Prfrd. Pharm |
90-Day Mail Order |
AARP Medicare Advantage Freedom Plus (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $167.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Freedom Plus (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $167.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Harmony (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $167.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Harmony (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $167.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage SecureHorizons Focus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $167.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
AARP Medicare Advantage SecureHorizons Focus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $167.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $167.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $167.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Plus Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$99.00 | $297.00 | None | $137.50 |
Browse Plan Formulary |
Aetna Medicare Plus Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$99.00 | $297.00 | None | $137.50 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $178.00 |
Browse Plan Formulary |
|
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $178.00 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $137.50 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $137.50 |
Browse Plan Formulary |
Align Connect (HMO C-SNP)
|
$0.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $45.00 | None | $103.50 |
Browse Plan Formulary |
Align Connect (HMO C-SNP)
|
$0.00 |
$480 | No | 2 |
Generic |
$15.00 | $45.00 | None | $103.50 |
Browse Plan Formulary |
Align Thrive (HMO I-SNP)
|
$0.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $45.00 | None | $103.50 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Align Thrive (HMO I-SNP)
|
$0.00 |
$480 | No | 2 |
Generic |
$15.00 | $45.00 | None | $103.50 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $237.50 | None | $160.50 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $237.50 | None | $160.50 |
Browse Plan Formulary |
Blue Shield 65 Plus Plan 2 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $237.50 | None | $160.50 |
Browse Plan Formulary |
Blue Shield 65 Plus Plan 2 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $237.50 | None | $160.50 |
Browse Plan Formulary |
Blue Shield AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $237.50 | None | $160.50 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Shield AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $237.50 | None | $160.50 |
Browse Plan Formulary |
Blue Shield Balance (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $237.50 | None | $160.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Blue Shield Balance (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $237.50 | None | $160.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Blue Shield Inspire (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $237.50 | None | $160.50 |
Browse Plan Formulary |
Blue Shield Inspire (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $237.50 | None | $160.50 |
Browse Plan Formulary |
Blue Shield Promise Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | All Generics, All Brands | 2 |
Tier 2 |
0% | 0% | None | $160.50 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Shield Promise Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No | 2 |
Tier 2 |
0% | 0% | None | $160.50 |
Browse Plan Formulary |
Blue Shield TotalDual Plan (HMO D-SNP)
|
$0.00 |
$480 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
25% | 25% | None | $167.00 |
Browse Plan Formulary |
Blue Shield Vital (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $237.50 | None | $167.00 |
Browse Plan Formulary |
Blue Shield Vital (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $237.50 | None | $167.00 |
Browse Plan Formulary |
Central Health Focus Plan (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 4 |
Non-Preferred Drug |
$75.00 | $150.00 | None | $104.50 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Central Health Focus Plan (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$75.00 | $150.00 | None | $104.50 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Central Health Medi-Medi Plan (HMO D-SNP)
|
$0.00 |
$480 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
25% | 25% | None | $104.50 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$75.00 | $150.00 | None | $104.50 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$75.00 | $150.00 | None | $104.50 |
Browse Plan Formulary |
Central Health Savings Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$99.00 | $198.00 | None | $104.50 |
Browse Plan Formulary |
Central Health Savings Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$99.00 | $198.00 | None | $104.50 |
Browse Plan Formulary |
Clever Care Fortune Medicare Advantage Plan (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $111.50 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Clever Care Fortune Medicare Advantage Plan (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $111.50 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Fortune Medicare Advantage Plan (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $104.50 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $111.50 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $111.50 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $104.50 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Value Medicare Advantage Plan (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$10.00 | $20.00 | None | $111.50 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Clever Care Value Medicare Advantage Plan (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$10.00 | $20.00 | None | $111.50 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Value Medicare Advantage Plan (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$10.00 | $20.00 | None | $104.50 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | All Generics, All Brands | 1 |
Tier 1 |
0% | 0% | None | $115.50 |
Browse Plan Formulary |
Health Net Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No | 1 |
Tier 1 |
0% | 0% | None | $115.50 |
Browse Plan Formulary |
Imperial Dynamic Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$75.00 | $180.00 | None | $156.00 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Imperial Dynamic Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$75.00 | $180.00 | None | $156.00 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Imperial Senior Value (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $157.50 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Imperial Senior Value (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $157.50 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Imperial Strong (HMO)
|
$0.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $157.50 |
Browse Plan Formulary |
Imperial Strong (HMO)
|
$0.00 |
$480 | No | 4 |
Tier 4 |
25% | 25% | None | $157.50 |
Browse Plan Formulary |
Imperial Traditional (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $157.50 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Imperial Traditional (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $157.50 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Inter Valley Health Plan Service To Seniors (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $10.00 | None | $116.00 |
Browse Plan Formulary select insulin pay $11-$35 copay but not this drug |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $10.00 | None | $211.00 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $10.00 | None | $211.00 |
Browse Plan Formulary |
L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | All Generics, All Brands | 1 |
Tier 1 |
0% | 0% | None | $130.50 |
Browse Plan Formulary |
L.A. Care Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No | 1 |
Tier 1 |
0% | 0% | None | $130.50 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 | All Generics, All Brands | 1 |
Tier 1 |
0% | 0% | None | $136.00 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No | 1 |
Tier 1 |
0% | 0% | None | $136.00 |
Browse Plan Formulary |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$12.00 | $24.00 | None | $156.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 | No | 2 |
Generic |
$12.00 | $24.00 | None | $156.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Molina Medicare Choice Care Select (HMO)
|
$0.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $40.00 | None | $156.00 |
Browse Plan Formulary |
Molina Medicare Choice Care Select (HMO)
|
$0.00 |
$480 | No | 2 |
Generic |
$20.00 | $40.00 | None | $156.00 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$0.00 |
$480 | No | 4 |
Non-Preferred Drug |
30% | 30% | None | $156.00 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SCAN Balance (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 4 |
Non-Preferred Drug |
$95.00 | $265.00 | None | $123.50 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
SCAN Balance (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $265.00 | None | $123.50 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
SCAN Classic (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $265.00 | None | $123.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SCAN Classic (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $265.00 | None | $123.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SCAN Connections (HMO D-SNP)
|
$0.00 |
$480 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
25% | 25% | None | $107.50 |
Browse Plan Formulary |
SCAN Connections at Home (HMO D-SNP)
|
$0.00 |
$480 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
25% | 25% | None | $107.50 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SCAN Embrace (HMO I-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 4 |
Non-Preferred Drug |
$99.00 | $277.00 | None | $123.50 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
SCAN Embrace (HMO I-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$99.00 | $277.00 | None | $123.50 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
SCAN Healthy at Home (HMO I-SNP)
|
$0.00 |
$0 | Some Generics | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $107.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SCAN Healthy at Home (HMO I-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $107.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SCAN Prime (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $265.00 | None | $123.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SCAN Venture (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $265.00 | None | $123.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SCAN Venture (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $265.00 | None | $123.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Chronic Complete (HMO C-SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $167.50 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
UnitedHealthcare Chronic Complete (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $167.50 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
Wellcare Dual Liberty (HMO D-SNP)
|
$0.00 |
$480 | No | 4 |
Non-Preferred Drug |
44% | 44% | None | $167.00 |
Browse Plan Formulary |
Wellcare Dual Liberty Freedom (HMO D-SNP)
|
$0.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
42% | 42% | None | $97.00 |
Browse Plan Formulary |
Wellcare Dual Liberty Freedom (HMO D-SNP)
|
$0.00 |
$480 | No | 4 |
Non-Preferred Drug |
42% | 42% | None | $97.00 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Wellcare Giveback (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | $0.00 | None | $100.00 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | $0.00 | None | $100.00 |
Browse Plan Formulary |
Wellcare Giveback Focus (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $0.00 | None | $114.00 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Wellcare Giveback Focus (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $0.00 | None | $114.00 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Wellcare Low Premium (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $167.00 |
Browse Plan Formulary |
Wellcare No Premium (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $158.50 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Wellcare No Premium (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $158.50 |
Browse Plan Formulary |
Wellcare No Premium Best (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $114.00 |
Browse Plan Formulary |
Wellcare No Premium Best (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $114.00 |
Browse Plan Formulary |
Wellcare Plus (HMO)
|
$0.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
42% | 42% | None | $78.50 |
Browse Plan Formulary |
Wellcare Plus (HMO)
|
$0.00 |
$480 | No | 4 |
Non-Preferred Drug |
42% | 42% | None | $78.50 |
Browse Plan Formulary |
Wellcare Specialty No Premium (HMO C-SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$8.00 | $0.00 | None | $158.50 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Wellcare Specialty No Premium (HMO C-SNP)
|
$0.00 |
$0 | No | 2 |
Generic |
$8.00 | $0.00 | None | $158.50 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Wellcare Low Premium (HMO)
|
$18.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $167.00 |
Browse Plan Formulary |
SCAN Prime (HMO)
|
$25.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $265.00 | None | $123.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Align Premier (HMO I-SNP)
|
$26.70 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $103.50 |
Browse Plan Formulary |
Align Premier (HMO I-SNP)
|
$26.70 |
$480 | No | 1 |
Tier 1 |
25% | 25% | None | $103.50 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$27.30 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Tier 2 |
$15.00 | $30.00 | None | $211.00 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$27.30 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Tier 2 |
$15.00 | $30.00 | None | $211.00 |
Browse Plan Formulary |
AARP Medicare Advantage SecureHorizons Premier (HMO)
|
$29.70 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $167.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage SecureHorizons Premier (HMO)
|
$29.70 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $167.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Kaiser Permanente Sr Adv Medicare Medi-Cal (HMO D-SNP)
|
$31.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $211.00 |
Browse Plan Formulary |
Kaiser Permanente Sr Adv Medicare Medi-Cal (HMO D-SNP)
|
$31.40 |
$480 | No | 2 |
Tier 2 |
15% | 15% | None | $211.00 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Assure (HMO)
|
$32.70 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $156.00 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
UnitedHealthcare Medicare Advantage Assure (HMO)
|
$32.70 |
$480 | No | 4 |
Tier 4 |
25% | 25% | None | $156.00 |
Browse Plan Formulary |
Blue Shield Coordinated Choice Plan (HMO)
|
$33.20 |
$480 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
25% | 25% | None | $167.00 |
Browse Plan Formulary |
Blue Shield Coordinated Choice Plan (HMO)
|
$33.20 |
$480 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
25% | 25% | None | $167.00 |
Browse Plan Formulary |
Blue Shield TotalDual Plan (HMO D-SNP)
|
$33.20 |
$480 | Few Generics | 4 |
Non-Preferred Drug |
25% | 25% | None | $167.00 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO D-SNP)
|
$33.20 |
$480 | Many Generics, Some Brands | 4 |
Non-Preferred Drug |
25% | 25% | None | $104.50 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$33.20 |
$480 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
25% | 25% | None | $104.50 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Central Health Premier Plan (HMO)
|
$33.20 |
$480 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
25% | 25% | None | $104.50 |
Browse Plan Formulary |
Clever Care Balance Medicare Advantage (HMO)
|
$33.20 |
$480 | Yes, this drug has Gap Coverage. | 2 |
Generic |
25% | 25% | None | $111.50 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Balance Medicare Advantage (HMO)
|
$33.20 |
$480 | Yes, this drug has Gap Coverage. | 2 |
Generic |
25% | 25% | None | $111.50 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Balance Medicare Advantage (HMO)
|
$33.20 |
$480 | Yes, this drug has Gap Coverage. | 2 |
Generic |
25% | 25% | None | $104.50 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Imperial Traditional Plus (HMO)
|
$33.20 |
$480 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
25% | 25% | None | $157.50 |
Browse Plan Formulary |
Imperial Traditional Plus (HMO)
|
$33.20 |
$480 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
25% | 25% | None | $157.50 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Inter Valley Health Plan Vitality Plus (HMO)
|
$33.20 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
25% | 25% | None | $116.00 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$33.20 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
30% | 30% | None | $156.00 |
Browse Plan Formulary |
SCAN Connections (HMO D-SNP)
|
$33.20 |
$480 | Some Generics | 4 |
Non-Preferred Drug |
25% | 25% | None | $107.50 |
Browse Plan Formulary |
SCAN Connections at Home (HMO D-SNP)
|
$33.20 |
$480 | Some Generics | 4 |
Non-Preferred Drug |
25% | 25% | None | $107.50 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$33.20 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
25% | 25% | None | $132.00 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$33.20 |
$480 | No | 4 |
Non-Preferred Drug |
25% | 25% | None | $132.00 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
VillageHealth (HMO-POS C-SNP)
|
$33.20 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
25% | 25% | None | $123.50 |
Browse Plan Formulary |
VillageHealth (HMO-POS C-SNP)
|
$33.20 |
$480 | No | 4 |
Non-Preferred Drug |
25% | 25% | None | $123.50 |
Browse Plan Formulary |
Wellcare Dual Liberty (HMO D-SNP)
|
$33.20 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
44% | 44% | None | $167.00 |
Browse Plan Formulary |
Wellcare Plus Sapphire I (HMO)
|
$33.20 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
46% | 46% | None | $167.00 |
Browse Plan Formulary |
Wellcare Plus Sapphire I (HMO)
|
$33.20 |
$480 | No | 4 |
Non-Preferred Drug |
46% | 46% | None | $167.00 |
Browse Plan Formulary |
Wellcare Plus Sapphire II (HMO)
|
$33.20 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
44% | 44% | None | $167.00 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Wellcare Plus Sapphire II (HMO)
|
$33.20 |
$480 | No | 4 |
Non-Preferred Drug |
44% | 44% | None | $167.00 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$48.50 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $137.50 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$90.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $137.50 |
Browse Plan Formulary |