LACOSAMIDE 200 MG TABLET [Vimpat] (60 TABLETS ) (NDC: 51991035106)
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 | Q:60 /30Days | $285.00 |
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 | Q:60 /30Days | $285.00 |
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 | Q:60 /30Days | $285.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $285.00 |
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 | Q:60 /30Days | $640.20 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days | $640.20 |
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 | Q:60 /30Days | $640.20 |
Browse Plan Formulary |
Align Connect (HMO C-SNP)
|
$0.00 |
$480* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$2.00 | $6.00 | None | $84.60 |
Browse Plan Formulary |
Align Thrive (HMO I-SNP)
|
$0.00 |
$480* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$2.00 | $6.00 | None | $84.60 |
Browse Plan Formulary |
Anthem MediBlue Care On Site (HMO I-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:60 /30Days | $41.40 |
Browse Plan Formulary |
Anthem MediBlue Diabetes Care (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:60 /30Days | $115.80 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
|
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Anthem MediBlue ESRD Care (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:60 /30Days | $115.80 |
Browse Plan Formulary |
Anthem MediBlue Heart Care (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:60 /30Days | $115.80 |
Browse Plan Formulary |
Anthem MediBlue Lung Care (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:60 /30Days | $115.80 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:60 /30Days | $115.80 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:60 /30Days | $115.80 |
Browse Plan Formulary |
Anthem MediBlue StartSmart Plus (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:60 /30Days | $115.80 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Anthem MediBlue Value Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:60 /30Days | $115.80 |
Browse Plan Formulary |
Astiva Health Advantage (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | Q:60 /30Days | $36.60 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
AVA (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$93.00 | $279.00 | None | $239.40 |
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 | Q:2 /1Days | $193.20 |
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 | Q:2 /1Days | $193.20 |
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 | Q:2 /1Days | $193.20 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Shield Inspire (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $237.50 | Q:2 /1Days | $193.20 |
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 | Q:2 /1Days | $193.20 |
Browse Plan Formulary |
Brand New Day Bridges Care Plan (HMO C-SNP)
|
$0.00 |
$0 | Some Generics | 2 |
Generic |
$5.00 | $10.00 | Q:60 /30Days | $132.60 |
Browse Plan Formulary |
Brand New Day Classic Care I Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | Q:60 /30Days | $132.60 |
Browse Plan Formulary |
Brand New Day Classic Care II Plan (HMO)
|
$0.00 |
$50 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$12.00 | $24.00 | Q:60 /30Days | $132.60 |
Browse Plan Formulary |
Brand New Day Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 | Some Generics | 2 |
Generic |
$9.00 | $18.00 | Q:60 /30Days | $132.60 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Brand New Day Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 | Some Generics | 2 |
Generic |
$9.00 | $18.00 | Q:60 /30Days | $132.60 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Brand New Day Harmony Care Plan (HMO C-SNP)
|
$0.00 |
$100 | Some Generics | 2 |
Generic |
$0.00 | $0.00 | Q:60 /30Days | $132.60 |
Browse Plan Formulary |
Brand New Day Part B Savings Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$12.00 | $12.00 | Q:60 /30Days | $132.60 |
Browse Plan Formulary |
Brand New Day Select Care I Plan (HMO I-SNP)
|
$0.00 |
$0 | Some Generics | 2 |
Generic |
$0.00 | $0.00 | Q:60 /30Days | $132.60 |
Browse Plan Formulary |
CalPlus (HMO)
|
$0.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
25% | 25% | None | $239.40 |
Browse Plan Formulary |
Central Health Focus Plan (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 2 |
Generic |
$0.00 | $0.00 | Q:60 /30Days | $132.60 |
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 Medicare Plan (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | Q:60 /30Days | $132.60 |
Browse Plan Formulary |
Central Health Savings Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $20.00 | Q:60 /30Days | $132.60 |
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 | Q:60 /30Days | $199.80 |
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 | Q:60 /30Days | $199.80 |
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 | Q:60 /30Days | $199.80 |
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 | Q:60 /30Days | $199.80 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | Q:60 /30Days | $199.80 |
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 | Q:60 /30Days | $199.80 |
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 | Q:60 /30Days | $199.80 |
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 | Q:60 /30Days | $199.80 |
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 | Q:60 /30Days | $199.80 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
ESRD Balance (HMO C-SNP)
|
$0.00 |
$0 | Few Generics | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $239.40 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Heart & Diabetes (HMO C-SNP)
|
$0.00 |
$0 | Some Generics | 4 |
Non-Preferred Drug |
$75.00 | $187.50 | None | $239.40 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:60 /30Days | $27.60 |
Browse Plan Formulary select insulin pay $35 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 | Q:60 /30Days | $39.00 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Imperial Senior Value (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:60 /30Days | $39.00 |
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% | Q:60 /30Days | $39.00 |
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 | Q:60 /30Days | $39.00 |
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 |
Inter Valley Health Plan Service To Seniors (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
25% | 25% | Q:60 /30Days | $87.00 |
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 | $21.60 |
Browse Plan Formulary |
My Choice (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $239.40 |
Browse Plan Formulary |
OneCare Connect (Medicare-Medicaid Plan)
|
$0.00 |
$0 | All Generics, All Brands | 1 |
Tier 1 |
0% | n/a | Q:60 /30Days | $132.60 |
Browse Plan Formulary |
Platinum (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$75.00 | $187.50 | None | $239.40 |
Browse Plan Formulary |
SCAN Balance (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 4 |
Non-Preferred Drug |
$95.00 | $265.00 | None | $192.00 |
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 |
SCAN Classic (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $265.00 | None | $192.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SCAN Embrace (HMO I-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 4 |
Non-Preferred Drug |
$99.00 | $277.00 | None | $192.00 |
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 | $192.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SCAN Heart First (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 4 |
Non-Preferred Drug |
$95.00 | $265.00 | None | $192.00 |
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 | $192.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
the ONE + Rite Aid (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $239.40 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
UnitedHealthcare Chronic Complete (HMO C-SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $285.00 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
Wellcare Giveback (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | $0.00 | Q:60 /30Days | $112.80 |
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 | Q:60 /30Days | $102.60 |
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 | Q:60 /30Days | $112.80 |
Browse Plan Formulary |
Wellcare Plus (HMO)
|
$0.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
42% | 42% | Q:60 /30Days | $124.80 |
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 | Q:60 /30Days | $102.60 |
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 |
Anthem MediBlue Coordination Plus (HMO)
|
$2.10 |
$480 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:60 /30Days | $115.80 |
Browse Plan Formulary |
Wellcare Low Premium (HMO)
|
$18.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$90.00 | $180.00 | Q:60 /30Days | $102.60 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$21.50 |
$480 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:60 /30Days | $115.80 |
Browse Plan Formulary |
AVA (PPO)
|
$22.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $239.40 |
Browse Plan Formulary |
AVA (PPO)
|
$22.50 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $239.40 |
Browse Plan Formulary |
Humana Value Plus H5619-037 (HMO)
|
$22.60 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:60 /30Days | $27.60 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Anthem MediBlue Extra (HMO)
|
$25.70 |
$480 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:60 /30Days | $115.80 |
Browse Plan Formulary |
SCAN Prime (HMO)
|
$26.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$95.00 | $265.00 | None | $192.00 |
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 | $84.60 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$27.30 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Tier 2 |
$15.00 | $30.00 | None | $21.60 |
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 | Q:60 /30Days | $285.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
OneCare (HMO D-SNP)
|
$30.80 |
$0 | Many Generics, Some Brands | 1 |
Generic |
$0.00 | n/a | Q:60 /30Days | $132.60 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
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 | $21.60 |
Browse Plan Formulary |
Brand New Day Classic Choice Plan (HMO)
|
$32.20 |
$480 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
25% | 25% | Q:60 /30Days | $132.60 |
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% | Q:60 /30Days | $285.00 |
Browse Plan Formulary |
Brand New Day Dual Access Plan (HMO D-SNP)
|
$32.90 |
$480 | Some Generics | 2 |
Generic |
25% | 25% | Q:60 /30Days | $132.60 |
Browse Plan Formulary |
Astiva Health Value (HMO)
|
$33.20 |
$480 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
25% | 25% | Q:60 /30Days | $36.60 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Blue Shield Coordinated Choice Plan (HMO)
|
$33.20 |
$480 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
25% | 25% | Q:2 /1Days | $193.20 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Shield TotalDual Plan (HMO D-SNP)
|
$33.20 |
$480 | Few Generics | 4 |
Non-Preferred Drug |
25% | 25% | Q:2 /1Days | $193.20 |
Browse Plan Formulary |
Brand New Day Bridges Choice Plan (HMO C-SNP)
|
$33.20 |
$480 | Some Generics | 2 |
Generic |
25% | 25% | Q:60 /30Days | $132.60 |
Browse Plan Formulary |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$33.20 |
$480 | Some Generics | 2 |
Generic |
25% | 25% | Q:60 /30Days | $132.60 |
Browse Plan Formulary |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$33.20 |
$480 | Some Generics | 2 |
Generic |
25% | 25% | Q:60 /30Days | $132.60 |
Browse Plan Formulary |
Brand New Day Harmony Choice Plan (HMO C-SNP)
|
$33.20 |
$480 | Some Generics | 2 |
Generic |
25% | 25% | Q:60 /30Days | $132.60 |
Browse Plan Formulary |
Brand New Day Select Choice I Plan (HMO I-SNP)
|
$33.20 |
$480 | Some Generics | 2 |
Generic |
$0.00 | $0.00 | Q:60 /30Days | $132.60 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Central Health Premier Plan (HMO)
|
$33.20 |
$480* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$0.00 | $0.00 | Q:60 /30Days | $132.60 |
Browse Plan Formulary |
Clever Care Balance Medicare Advantage (HMO)
|
$33.20 |
$480 | Yes, this drug has Gap Coverage. | 2 |
Generic |
25% | 25% | Q:60 /30Days | $199.80 |
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% | Q:60 /30Days | $199.80 |
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% | Q:60 /30Days | $199.80 |
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% | Q:60 /30Days | $39.00 |
Browse Plan Formulary |
Inter Valley Health Plan Vitality Plus (HMO)
|
$33.20 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
25% | 25% | Q:60 /30Days | $87.00 |
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 Plus (HMO)
|
$33.20 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
25% | 25% | None | $192.00 |
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% | Q:60 /30Days | $102.60 |
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% | Q:60 /30Days | $102.60 |
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% | Q:60 /30Days | $102.60 |
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 | Q:60 /30Days | $640.20 |
Browse Plan Formulary |
Anthem MediBlue Access (PPO)
|
$172.00 |
$370 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:60 /30Days | $115.80 |
Browse Plan Formulary |