SPIRIVA RESPIMAT INHAL SPRAY (4 GM ) (NDC: 00597010061)
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. | 3 |
Preferred Brand |
$35.00 | $95.00 | Q:4 /30Days | $529.80 |
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. | 3 |
Preferred Brand |
$35.00 | $95.00 | Q:4 /30Days | $529.80 |
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. | 3 |
Preferred Brand |
$35.00 | $95.00 | Q:4 /30Days | $529.80 |
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. | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:4 /30Days | $529.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Anthem MediBlue Care On Site (HMO I-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 3 |
Preferred Brand |
$37.50 | $75.00 | Q:4 /30Days | $477.40 |
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 |
Anthem MediBlue Diabetes Care (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 3 |
Preferred Brand |
$35.00 | $70.00 | Q:4 /30Days | $537.16 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Anthem MediBlue ESRD Care (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 3 |
Preferred Brand |
$37.50 | $75.00 | Q:4 /30Days | $537.16 |
Browse Plan Formulary |
Anthem MediBlue Heart Care (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 3 |
Preferred Brand |
$37.50 | $75.00 | Q:4 /30Days | $537.16 |
Browse Plan Formulary |
Anthem MediBlue Lung Care (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 3 |
Preferred Brand |
$37.50 | $75.00 | Q:4 /30Days | $537.16 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:4 /30Days | $537.16 |
Browse Plan Formulary |
Anthem MediBlue Select (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | Q:4 /30Days | $537.16 |
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 StartSmart Plus (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $90.00 | Q:4 /30Days | $537.20 |
Browse Plan Formulary |
Anthem MediBlue Value Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$37.50 | $75.00 | Q:4 /30Days | $537.16 |
Browse Plan Formulary |
Astiva Health Advantage (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$32.00 | $64.00 | Q:4 /30Days | $503.20 |
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. | 3 |
Preferred Brand |
$40.00 | $120.00 | Q:4 /30Days | $514.56 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$38.00 | $95.00 | Q:4 /30Days | $480.60 |
Browse Plan Formulary |
Blue Shield 65 Plus Plan 2 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | Q:4 /30Days | $480.44 |
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. | 3 |
Preferred Brand |
$40.00 | $100.00 | Q:4 /30Days | $480.60 |
Browse Plan Formulary |
Blue Shield Inspire (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $87.50 | Q:4 /30Days | $480.60 |
Browse Plan Formulary |
Blue Shield Vital (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $100.00 | Q:4 /30Days | $480.72 |
Browse Plan Formulary |
Brand New Day Bridges Care Plan (HMO C-SNP)
|
$0.00 |
$0 | Some Generics | 3 |
Preferred Brand |
$45.00 | $90.00 | Q:4 /30Days | $482.60 |
Browse Plan Formulary |
Brand New Day Classic Care I Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:4 /30Days | $482.60 |
Browse Plan Formulary |
Brand New Day Classic Care II Plan (HMO)
|
$0.00 |
$50 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:4 /30Days | $482.60 |
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 |
Brand New Day Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 | Some Generics | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:4 /30Days | $482.60 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Brand New Day Embrace Care Plan (HMO C-SNP)
|
$0.00 |
$0 | Some Generics | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:4 /30Days | $482.60 |
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 | 3 |
Preferred Brand |
$45.00 | $90.00 | Q:4 /30Days | $482.60 |
Browse Plan Formulary |
Brand New Day Part B Savings Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:4 /30Days | $482.60 |
Browse Plan Formulary |
Brand New Day Select Care I Plan (HMO I-SNP)
|
$0.00 |
$0 | Some Generics | 3 |
Preferred Brand |
$0.00 | $0.00 | Q:4 /30Days | $482.60 |
Browse Plan Formulary |
CalPlus (HMO)
|
$0.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | 25% | Q:4 /30Days | $515.76 |
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 Focus Plan (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 3 |
Preferred Brand |
$35.00 | $70.00 | Q:4 /30Days | $482.56 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $70.00 | Q:4 /30Days | $482.60 |
Browse Plan Formulary |
Central Health Savings Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:4 /30Days | $482.60 |
Browse Plan Formulary |
Clever Care Fortune Medicare Advantage Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $70.00 | Q:4 /30Days | $482.60 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Fortune Medicare Advantage Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $70.00 | Q:4 /30Days | $482.60 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Fortune Medicare Advantage Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $70.00 | Q:4 /30Days | $482.56 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $70.00 | Q:4 /30Days | $482.60 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $70.00 | Q:4 /30Days | $482.60 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Longevity Medicare Advantage (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $70.00 | Q:4 /30Days | $482.56 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Value Medicare Advantage Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:4 /30Days | $482.60 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Value Medicare Advantage Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:4 /30Days | $482.60 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Value Medicare Advantage Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | Q:4 /30Days | $482.56 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
ESRD Balance (HMO C-SNP)
|
$0.00 |
$0 | Few Generics | 3 |
Preferred Brand |
$40.00 | $120.00 | Q:4 /30Days | $514.64 |
Browse Plan Formulary |
Heart & Diabetes (HMO C-SNP)
|
$0.00 |
$0 | Some Generics | 3 |
Preferred Brand |
$30.00 | $75.00 | Q:4 /30Days | $515.12 |
Browse Plan Formulary |
Humana Gold Plus H5619-021 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$35.00 | $70.00 | Q:4 /28Days | $538.80 |
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. | 3 |
Preferred Brand |
$30.00 | $75.00 | Q:4 /30Days | $502.92 |
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 | 3 |
Preferred Brand |
$45.00 | $90.00 | Q:4 /30Days | $503.24 |
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 | 3 |
Tier 3 |
25% | 25% | Q:4 /30Days | $503.24 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Additional Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Imperial Traditional (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $90.00 | Q:4 /30Days | $503.24 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Inter Valley Health Plan Service To Seniors (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $117.50 | Q:4 /30Days | $531.04 |
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, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | None | $261.48 |
Browse Plan Formulary |
My Choice (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$30.00 | $75.00 | Q:4 /30Days | $515.44 |
Browse Plan Formulary |
OneCare Connect (Medicare-Medicaid Plan)
|
$0.00 |
$0 | All Generics, All Brands | 2 |
Tier 2 |
0% | n/a | Q:4 /30Days | $519.00 |
Browse Plan Formulary |
Platinum (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$30.00 | $75.00 | Q:4 /30Days | $514.64 |
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 | 3 |
Preferred Brand |
$30.00 | $70.00 | None | $529.36 |
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. | 3 |
Preferred Brand |
$30.00 | $70.00 | None | $530.28 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SCAN Embrace (HMO I-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 3 |
Preferred Brand |
$37.00 | $91.00 | None | $530.28 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
SCAN Healthy at Home (HMO I-SNP)
|
$0.00 |
$0 | Some Generics | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $529.84 |
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 | 3 |
Preferred Brand |
$37.00 | $91.00 | None | $530.28 |
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. | 3 |
Preferred Brand |
$30.00 | $70.00 | None | $529.36 |
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 |
the ONE + Rite Aid (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $120.00 | Q:4 /30Days | $515.32 |
Browse Plan Formulary |
UnitedHealthcare Chronic Complete (HMO C-SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 3 |
Preferred Brand |
$35.00 | $95.00 | Q:4 /30Days | $529.80 |
Browse Plan Formulary select insulin pay $25 copay but not this drug |
Anthem MediBlue Coordination Plus (HMO)
|
$2.10 |
$480 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:4 /30Days | $537.16 |
Browse Plan Formulary |
Anthem MediBlue Connect Plus (HMO)
|
$21.50 |
$480 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
25% | 25% | Q:4 /30Days | $537.24 |
Browse Plan Formulary |
AVA (PPO)
|
$22.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $120.00 | Q:4 /30Days | $514.88 |
Browse Plan Formulary |
AVA (PPO)
|
$22.50 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$40.00 | $120.00 | Q:4 /30Days | $514.56 |
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 |
Humana Value Plus H5619-037 (HMO)
|
$22.60 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:4 /28Days | $538.52 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$25.70 |
$480 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:4 /30Days | $537.72 |
Browse Plan Formulary |
SCAN Prime (HMO)
|
$26.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$30.00 | $70.00 | None | $530.28 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$27.30 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Tier 3 |
$47.00 | $94.00 | None | $264.80 |
Browse Plan Formulary |
AARP Medicare Advantage SecureHorizons Premier (HMO)
|
$29.70 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:4 /30Days | $529.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
OneCare (HMO D-SNP)
|
$30.80 |
$0 | Many Generics, Some Brands | 2 |
Tier 2 |
$0.00 | n/a | Q:4 /30Days | $519.00 |
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 Sr Adv Medicare Medi-Cal (HMO D-SNP)
|
$31.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | None | $268.32 |
Browse Plan Formulary |
Brand New Day Classic Choice Plan (HMO)
|
$32.20 |
$480 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
25% | 25% | Q:4 /30Days | $482.60 |
Browse Plan Formulary |
UnitedHealthcare Medicare Advantage Assure (HMO)
|
$32.70 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | Q:4 /30Days | $529.96 |
Browse Plan Formulary |
Brand New Day Dual Access Plan (HMO D-SNP)
|
$32.90 |
$480 | Some Generics | 3 |
Preferred Brand |
25% | 25% | Q:4 /30Days | $482.60 |
Browse Plan Formulary |
Astiva Health Value (HMO)
|
$33.20 |
$480 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
25% | 25% | Q:4 /30Days | $503.20 |
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. | 3 |
Preferred Brand |
25% | 25% | Q:4 /30Days | $483.32 |
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 | 3 |
Preferred Brand |
25% | 25% | Q:4 /30Days | $483.20 |
Browse Plan Formulary |
Brand New Day Bridges Choice Plan (HMO C-SNP)
|
$33.20 |
$480 | Some Generics | 3 |
Preferred Brand |
25% | 25% | Q:4 /30Days | $482.60 |
Browse Plan Formulary |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$33.20 |
$480 | Some Generics | 3 |
Preferred Brand |
25% | 25% | Q:4 /30Days | $482.60 |
Browse Plan Formulary |
Brand New Day Embrace Choice Plan (HMO C-SNP)
|
$33.20 |
$480 | Some Generics | 3 |
Preferred Brand |
25% | 25% | Q:4 /30Days | $482.60 |
Browse Plan Formulary |
Brand New Day Harmony Choice Plan (HMO C-SNP)
|
$33.20 |
$480 | Some Generics | 3 |
Preferred Brand |
25% | 25% | Q:4 /30Days | $482.60 |
Browse Plan Formulary |
Brand New Day Select Choice I Plan (HMO I-SNP)
|
$33.20 |
$480 | Some Generics | 3 |
Preferred Brand |
25% | 25% | Q:4 /30Days | $482.60 |
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, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
25% | 25% | Q:4 /30Days | $482.60 |
Browse Plan Formulary |
Clever Care Balance Medicare Advantage (HMO)
|
$33.20 |
$480 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
25% | 25% | Q:4 /30Days | $482.60 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Balance Medicare Advantage (HMO)
|
$33.20 |
$480 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
25% | 25% | Q:4 /30Days | $482.56 |
Browse Plan Formulary select insulin pay $0-$35 copay but not this drug |
Clever Care Balance Medicare Advantage (HMO)
|
$33.20 |
$480 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
25% | 25% | Q:4 /30Days | $482.60 |
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. | 3 |
Preferred Brand |
25% | 25% | Q:4 /30Days | $503.24 |
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:4 /30Days | $531.04 |
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 | 3 |
Preferred Brand |
25% | 25% | None | $529.72 |
Browse Plan Formulary |
Anthem MediBlue Access (PPO)
|
$172.00 |
$370 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | Q:4 /30Days | $536.80 |
Browse Plan Formulary |