TOVIAZ TABLETS 4MG EXTENDED RELEASE (30 BOT) (NDC: 00069024230)
2015 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
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 |
Anthem Dual Advantage (HMO SNP)
![Email Prescription and/or Health Benefit details for Anthem Dual Advantage (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$31.00 | $93.00 | Q:30 /30Days | $233.94 |
Browse Plan Formulary |
Anthem Senior Advantage Basic (HMO)
![Email Prescription and/or Health Benefit details for Anthem Senior Advantage Basic (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$153 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$37.00 | $111.00 | Q:30 /30Days | $234.01 |
Browse Plan Formulary |
CareSource MyCare Ohio (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for CareSource MyCare Ohio (Medicare-Medicaid Plan)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Brand Drugs |
0% | 0% | Q:30 /30Days | $233.66 |
Browse Plan Formulary |
Gateway Health Medicare Assured Select (HMO)
![Email Prescription and/or Health Benefit details for Gateway Health Medicare Assured Select (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days | $237.37 |
Browse Plan Formulary |
HealthSpan Medicare Standard (HMO)
![Email Prescription and/or Health Benefit details for HealthSpan Medicare Standard (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $235.39 |
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 Gold Plus H8953-006 (HMO)
![Email Prescription and/or Health Benefit details for Humana Gold Plus H8953-006 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$320* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days | $233.05 |
Browse Plan Formulary |
PrimeTime Health Plan Aultimate (HMO-POS)
![Email Prescription and/or Health Benefit details for PrimeTime Health Plan Aultimate (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:30 /30Days | $238.68 |
Browse Plan Formulary |
SummaCare Medicare Topaz (HMO)
![Email Prescription and/or Health Benefit details for SummaCare Medicare Topaz (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$100 |
to be determined |
3 |
Tier 3 |
$45.00 | $112.50 | None | $235.28 |
Browse Plan Formulary |
UnitedHealthcare Connected for MyCareOhio (Medicare-Medicaid Plan)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Connected for MyCareOhio (Medicare-Medicaid Plan)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Brand Drugs |
0% | 0% | None | $232.56 |
Browse Plan Formulary |
HealthSpan Medicare Core 2 (HMO)
![Email Prescription and/or Health Benefit details for HealthSpan Medicare Core 2 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$2.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $235.20 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Dual Complete (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$11.60 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $232.51 |
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 |
HealthSpan Medicare Plus IV (Cost)
![Email Prescription and/or Health Benefit details for HealthSpan Medicare Plus IV (Cost)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$27.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $235.99 |
Browse Plan Formulary |
Gateway Health Medicare Assured Diamond (HMO SNP)
![Email Prescription and/or Health Benefit details for Gateway Health Medicare Assured Diamond (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$28.60 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | n/a | Q:30 /30Days | $237.37 |
Browse Plan Formulary |
Gateway Health Medicare Assured Ruby (HMO SNP)
![Email Prescription and/or Health Benefit details for Gateway Health Medicare Assured Ruby (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$28.60 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | Q:30 /30Days | $237.37 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
![Email Prescription and/or Health Benefit details for UnitedHealthcare Nursing Home Plan (PPO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$28.60 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | None | $232.51 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
![Email Prescription and/or Health Benefit details for AARP MedicareComplete Plan 1 (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $232.76 |
Browse Plan Formulary |
PrimeTime Health Plan Classic (HMO-POS)
![Email Prescription and/or Health Benefit details for PrimeTime Health Plan Classic (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$29.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:30 /30Days | $238.68 |
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 |
SummaCare Medicare Ruby (HMO)
![Email Prescription and/or Health Benefit details for SummaCare Medicare Ruby (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$32.00 |
$0 |
to be determined |
3 |
Tier 3 |
$45.00 | $112.50 | None | $235.28 |
Browse Plan Formulary |
HumanaChoice R5826-007 (Regional PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice R5826-007 (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$32.90 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
3* |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days | $231.97 |
Browse Plan Formulary |
HealthSpan Medicare Plus III (Cost)
![Email Prescription and/or Health Benefit details for HealthSpan Medicare Plus III (Cost)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$37.10 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $235.99 |
Browse Plan Formulary |
Gateway Health Medicare Assured Gold (HMO SNP)
![Email Prescription and/or Health Benefit details for Gateway Health Medicare Assured Gold (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$39.80 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days | $237.37 |
Browse Plan Formulary |
Blue Medicare Access Value (Regional PPO)
![Email Prescription and/or Health Benefit details for Blue Medicare Access Value (Regional PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$40.80 |
$115 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days | $233.78 |
Browse Plan Formulary |
HealthSpan Medicare Plus II (Cost)
![Email Prescription and/or Health Benefit details for HealthSpan Medicare Plus II (Cost)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$42.10 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $235.99 |
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 |
HealthSpan Medicare Enhanced (HMO)
![Email Prescription and/or Health Benefit details for HealthSpan Medicare Enhanced (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$52.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $190.00 | None | $235.39 |
Browse Plan Formulary |
HealthSpan Medicare Plus I - B only (Cost)
![Email Prescription and/or Health Benefit details for HealthSpan Medicare Plus I - B only (Cost)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$52.10 |
$0 |
to be determined |
4 |
Tier 4 |
$95.00 | $190.00 | None | $235.99 |
Browse Plan Formulary |
Gateway Health Medicare Assured Choice (HMO)
![Email Prescription and/or Health Benefit details for Gateway Health Medicare Assured Choice (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$57.80 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days | $237.37 |
Browse Plan Formulary |
Anthem Senior Advantage Plus (HMO)
![Email Prescription and/or Health Benefit details for Anthem Senior Advantage Plus (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$64.00 |
$123 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days | $233.90 |
Browse Plan Formulary |
PrimeTime Health Plan Plus (HMO-POS)
![Email Prescription and/or Health Benefit details for PrimeTime Health Plan Plus (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$69.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | Q:30 /30Days | $238.68 |
Browse Plan Formulary |
Anthem Medicare Preferred Standard (PPO)
![Email Prescription and/or Health Benefit details for Anthem Medicare Preferred Standard (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$71.00 |
$165 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days | $233.70 |
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 Medicare Preferred Standard (PPO)
![Email Prescription and/or Health Benefit details for Anthem Medicare Preferred Standard (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$71.00 |
$165 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days | $234.65 |
Browse Plan Formulary |
HumanaChoice H6609-082 (PPO)
![Email Prescription and/or Health Benefit details for HumanaChoice H6609-082 (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$72.00 |
$320* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days | $232.52 |
Browse Plan Formulary |
Gateway Health Medicare Assured Platinum (HMO SNP)
![Email Prescription and/or Health Benefit details for Gateway Health Medicare Assured Platinum (HMO SNP)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$77.80 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days | $237.37 |
Browse Plan Formulary |
SummaCare Medicare Sapphire (HMO-POS)
![Email Prescription and/or Health Benefit details for SummaCare Medicare Sapphire (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$78.00 |
$0 |
to be determined |
3 |
Tier 3 |
$45.00 | $112.50 | None | $235.28 |
Browse Plan Formulary |
Gateway Health Medicare Assured Prime (HMO)
![Email Prescription and/or Health Benefit details for Gateway Health Medicare Assured Prime (HMO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$82.80 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:30 /30Days | $237.37 |
Browse Plan Formulary |
Anthem Medicare Preferred Select (PPO)
![Email Prescription and/or Health Benefit details for Anthem Medicare Preferred Select (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$91.00 |
$151 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days | $233.86 |
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 Medicare Preferred Select (PPO)
![Email Prescription and/or Health Benefit details for Anthem Medicare Preferred Select (PPO)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$91.00 |
$151 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | Q:30 /30Days | $234.07 |
Browse Plan Formulary |
HealthSpan Medicare Plus I (Cost)
![Email Prescription and/or Health Benefit details for HealthSpan Medicare Plus I (Cost)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$148.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Tier 4 |
$95.00 | $190.00 | None | $235.99 |
Browse Plan Formulary |
SummaCare Medicare Emerald (HMO-POS)
![Email Prescription and/or Health Benefit details for SummaCare Medicare Emerald (HMO-POS)](https://q1medicare.com/pics/ContentPics/email_medicare_plan_details.png) |
$182.00 |
$0 |
to be determined |
3 |
Tier 3 |
$45.00 | $112.50 | None | $235.31 |
Browse Plan Formulary |