ADALIMUMAB 50 MG/ML PREFILLED SYRINGE [HUMIRA] (0.4 ML ) (NDC: 00074937402)
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 |
Advantra Silver (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:2 /28Days | $3,344.46 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:2 /28Days | $3,425.91 |
Browse Plan Formulary |
Anthem Dual Advantage (HMO SNP)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:2 /28Days | $3,250.43 |
Browse Plan Formulary |
Anthem Senior Advantage Basic (HMO)
|
$0.00 |
$153* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | n/a | P Q:2 /28Days | $3,250.43 |
Browse Plan Formulary |
Buckeye Health Plan - MyCareOhio (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Brand Drugs |
0% | 0% | P | $3,342.15 |
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 |
CareSource MyCare Ohio (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Brand Drugs |
0% | 0% | P | $3,446.62 |
Browse Plan Formulary |
Gateway Health Medicare Assured Select (HMO)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:12 /28Days | $3,342.14 |
Browse Plan Formulary |
HealthSpan Medicare Standard (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | None | $3,350.12 |
Browse Plan Formulary |
SummaCare Medicare Topaz (HMO)
|
$0.00 |
$100* |
to be determined |
5* |
Tier 5 |
33% | 33% | P | $3,333.83 |
Browse Plan Formulary |
UnitedHealthcare Connected for MyCareOhio (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Brand Drugs |
0% | 0% | P | $3,313.78 |
Browse Plan Formulary |
HealthSpan Medicare Core 2 (HMO)
|
$2.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | None | $3,350.12 |
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 Dual Complete (HMO SNP)
|
$11.60 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
15% | 15% | P | $3,213.13 |
Browse Plan Formulary |
Paramount Elite - Standard Medical and Drug (HMO)
|
$23.00 |
$100* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | n/a | P Q:2 /28Days | $3,246.05 |
Browse Plan Formulary |
HealthSpan Medicare Plus IV (Cost)
|
$27.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | None | $3,342.09 |
Browse Plan Formulary |
Buckeye Health Plan Advantage (HMO SNP)
|
$28.60 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | P | $3,342.15 |
Browse Plan Formulary |
Gateway Health Medicare Assured Diamond (HMO SNP)
|
$28.60 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | n/a | P Q:12 /28Days | $3,342.14 |
Browse Plan Formulary |
Gateway Health Medicare Assured Ruby (HMO SNP)
|
$28.60 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | P Q:12 /28Days | $3,342.14 |
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 Nursing Home Plan (PPO SNP)
|
$28.60 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Tier 5 |
25% | 25% | P | $3,213.13 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
|
$29.00 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | 33% | P | $3,313.78 |
Browse Plan Formulary |
Humana Gold Plus H8953-002 (HMO)
|
$29.00 |
$320 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P Q:6 /28Days | $3,315.16 |
Browse Plan Formulary |
SummaCare Medicare Ruby (HMO)
|
$32.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P | $3,333.83 |
Browse Plan Formulary |
HumanaChoice R5826-007 (Regional PPO)
|
$32.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
25% | n/a | P Q:6 /28Days | $3,283.28 |
Browse Plan Formulary |
HealthSpan Medicare Plus III (Cost)
|
$37.10 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | None | $3,342.06 |
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 |
Gateway Health Medicare Assured Gold (HMO SNP)
|
$39.80 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:12 /28Days | $3,342.14 |
Browse Plan Formulary |
Blue Medicare Access Value (Regional PPO)
|
$40.80 |
$115* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | n/a | P Q:2 /28Days | $3,250.43 |
Browse Plan Formulary |
HealthSpan Medicare Plus II (Cost)
|
$42.10 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | None | $3,342.09 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$47.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:2 /28Days | $3,344.46 |
Browse Plan Formulary |
HealthSpan Medicare Enhanced (HMO)
|
$52.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | 33% | None | $3,350.12 |
Browse Plan Formulary |
HealthSpan Medicare Plus I - B only (Cost)
|
$52.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | None | $3,342.09 |
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)
|
$56.00 |
$165* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | n/a | P Q:2 /28Days | $3,257.35 |
Browse Plan Formulary |
Anthem Medicare Preferred Standard (PPO)
|
$56.00 |
$165* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | n/a | P Q:2 /28Days | $3,328.97 |
Browse Plan Formulary |
Gateway Health Medicare Assured Choice (HMO)
|
$57.80 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:12 /28Days | $3,342.14 |
Browse Plan Formulary |
Paramount Elite - Enhanced Medical and Drug (HMO)
|
$68.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:2 /28Days | $3,246.05 |
Browse Plan Formulary |
HumanaChoice H6609-082 (PPO)
|
$72.00 |
$320 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | P Q:6 /28Days | $3,315.16 |
Browse Plan Formulary |
Gateway Health Medicare Assured Platinum (HMO SNP)
|
$77.80 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:12 /28Days | $3,342.14 |
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 Sapphire (HMO-POS)
|
$78.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P | $3,333.83 |
Browse Plan Formulary |
Gateway Health Medicare Assured Prime (HMO)
|
$82.80 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:12 /28Days | $3,342.14 |
Browse Plan Formulary |
Anthem Medicare Preferred Select (PPO)
|
$91.00 |
$151* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | n/a | P Q:2 /28Days | $3,257.35 |
Browse Plan Formulary |
Anthem Medicare Preferred Select (PPO)
|
$91.00 |
$151* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Specialty Tier |
33% | n/a | P Q:2 /28Days | $3,328.97 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$100.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:2 /28Days | $3,267.16 |
Browse Plan Formulary |
Aetna Medicare Select Plus Plan (PPO)
|
$139.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | P Q:2 /28Days | $3,265.99 |
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 Plus I (Cost)
|
$148.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Tier 5 |
33% | 33% | None | $3,342.09 |
Browse Plan Formulary |
SummaCare Medicare Emerald (HMO-POS)
|
$182.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P | $3,333.83 |
Browse Plan Formulary |