FANAPT 4 MG TABLET (60 EA ) (NDC: 43068010402)
2019 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 MedicareComplete Plan 7 (HMO)
|
$0.00 |
$225 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | S Q:60 /30Days | $1,205.86 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days | $1,200.79 |
Browse Plan Formulary |
Allwell Medicare (HMO)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None | $1,199.62 |
Browse Plan Formulary |
Anthem MediBlue Essential (HMO)
|
$0.00 |
$60 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
31% | n/a | S Q:180 /30Days | $1,196.31 |
Browse Plan Formulary |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | S Q:180 /30Days | $1,196.28 |
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 Prime Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | S Q:180 /30Days | $1,179.74 |
Browse Plan Formulary |
CareSource Advantage Zero Premium (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | Q:60 /30Days | $1,162.57 |
Browse Plan Formulary |
CareSource MyCare Ohio (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | 0% | Q:60 /30Days | $1,162.57 |
Browse Plan Formulary |
Humana Cleveland Clinic Preferred (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:60 /30Days | $1,236.49 |
Browse Plan Formulary |
Humana Gold Plus H6622-014 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:60 /30Days | $1,236.49 |
Browse Plan Formulary |
HumanaChoice H5525-042 (PPO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:60 /30Days | $1,235.92 |
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 |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$160 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days | $1,160.04 |
Browse Plan Formulary |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$160 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days | $1,199.56 |
Browse Plan Formulary |
MeridianCare Essential (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | Q:60 /30Days | $1,181.32 |
Browse Plan Formulary |
Paramount Elite - Standard Medical and Drug (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:60 /30Days | $1,162.57 |
Browse Plan Formulary |
PrimeTime Health Plan Aultimate (HMO-POS)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,194.89 |
Browse Plan Formulary |
SummaCare Medicare Topaz (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | S Q:60 /30Days | $1,143.35 |
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 |
The Health Plan SecureCare - Option IV (HMO)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:60 /30Days | $1,191.43 |
Browse Plan Formulary |
UnitedHealthcare Connected for MyCareOhio (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | 0% | S Q:60 /30Days | $1,209.74 |
Browse Plan Formulary |
HumanaChoice H5216-106 (PPO)
|
$15.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:60 /30Days | $1,236.49 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
|
$18.00 |
$170 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | S Q:60 /30Days | $1,205.86 |
Browse Plan Formulary |
Aetna Medicare OH Connect Gold 2 (Regional PPO)
|
$21.50 |
$350 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days | $1,201.98 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$25.60 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
All Formulary Drugs |
15% | 15% | S Q:60 /30Days | $1,205.68 |
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 |
HumanaChoice R5495-002 (Regional PPO)
|
$26.40 |
$395 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:60 /30Days | $1,235.92 |
Browse Plan Formulary |
Paramount Elite - Prime Medical and Drug (HMO)
|
$28.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:60 /30Days | $1,162.57 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H6622-015 (HMO SNP)
|
$31.20 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:60 /30Days | $1,236.49 |
Browse Plan Formulary |
Aetna Better Health of Ohio Dual Preferred (HMO SNP)
|
$32.10 |
$220 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days | $1,201.28 |
Browse Plan Formulary |
Allwell Dual Medicare (HMO SNP)
|
$32.90 |
$50 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $1,164.06 |
Browse Plan Formulary |
Anthem MediBlue Dual Advantage (HMO SNP)
|
$32.90 |
$415 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | S Q:180 /30Days | $1,196.28 |
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)
|
$32.90 |
$415 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | S Q:180 /30Days | $1,196.28 |
Browse Plan Formulary |
CareSource Advantage (HMO)
|
$32.90 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | Q:60 /30Days | $1,162.57 |
Browse Plan Formulary |
Gateway Health Medicare Assured Diamond (HMO SNP)
|
$32.90 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:60 /30Days | $1,158.80 |
Browse Plan Formulary |
Gateway Health Medicare Assured Ruby (HMO SNP)
|
$32.90 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | P Q:60 /30Days | $1,158.80 |
Browse Plan Formulary |
MeridianCare Extra (HMO SNP)
|
$32.90 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
25% | 25% | Q:60 /30Days | $1,181.32 |
Browse Plan Formulary |
Provider Partners Health Plan of Ohio (HMO SNP)
|
$32.90 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
All Formulary Drugs |
25% | 25% | P Q:60 /30Days | $1,200.43 |
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 1 (PPO SNP)
|
$32.90 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
All Formulary Drugs |
25% | 25% | S Q:60 /30Days | $1,210.44 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 2 (PPO SNP)
|
$32.90 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
All Formulary Drugs |
25% | 25% | S Q:60 /30Days | $1,210.02 |
Browse Plan Formulary |
The Health Plan SecureCare SNP (HMO SNP)
|
$36.70 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
All Formulary Drugs |
15% | 15% | Q:60 /30Days | $1,176.07 |
Browse Plan Formulary |
MedMutual Advantage Choice (HMO)
|
$38.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days | $1,160.04 |
Browse Plan Formulary |
MedMutual Advantage Choice (HMO)
|
$38.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days | $1,199.56 |
Browse Plan Formulary |
MedMutual Advantage Select (PPO)
|
$38.00 |
$160 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days | $1,160.04 |
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 |
MedMutual Advantage Select (PPO)
|
$38.00 |
$160 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days | $1,199.56 |
Browse Plan Formulary |
PrimeTime Health Plan Classic (HMO-POS)
|
$39.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $1,194.89 |
Browse Plan Formulary |
SummaCare Medicare Ruby (HMO)
|
$43.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | S Q:60 /30Days | $1,143.35 |
Browse Plan Formulary |
The Health Plan SecureCare - Option II (HMO)
|
$46.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:60 /30Days | $1,191.43 |
Browse Plan Formulary |
Aetna Medicare OH Connect Gold (Regional PPO)
|
$53.30 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days | $1,201.98 |
Browse Plan Formulary |
Anthem MediBlue Access Basic (Regional PPO)
|
$57.80 |
$200 |
to be determined |
5 |
Specialty Tier |
29% | n/a | S Q:180 /30Days | $1,196.28 |
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 Plus (HMO)
|
$63.00 |
$60 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
31% | n/a | S Q:180 /30Days | $1,210.79 |
Browse Plan Formulary |
The Health Plan SecureChoice - Option II (PPO)
|
$66.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$85.00 | $170.00 | Q:60 /30Days | $1,191.43 |
Browse Plan Formulary |
CareSource Advantage Plus (HMO)
|
$67.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | Q:60 /30Days | $1,162.57 |
Browse Plan Formulary |
Anthem MediBlue Access (PPO)
|
$68.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
32% | n/a | S Q:180 /30Days | $1,174.08 |
Browse Plan Formulary |
Anthem MediBlue Access (PPO)
|
$68.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
32% | n/a | S Q:180 /30Days | $1,201.19 |
Browse Plan Formulary |
Paramount Elite - Enhanced Medical and Drug (HMO)
|
$68.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | Q:60 /30Days | $1,162.57 |
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 |
MedMutual Advantage Preferred (PPO)
|
$74.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days | $1,160.04 |
Browse Plan Formulary |
MedMutual Advantage Preferred (PPO)
|
$74.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days | $1,199.56 |
Browse Plan Formulary |
HumanaChoice H5216-024 (PPO)
|
$75.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P Q:60 /30Days | $1,236.49 |
Browse Plan Formulary |
SummaCare Medicare Sapphire (HMO-POS)
|
$76.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$100.00 | $300.00 | S Q:60 /30Days | $1,143.35 |
Browse Plan Formulary |
Anthem MediBlue Access Plus (PPO)
|
$87.00 |
$40 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
32% | n/a | S Q:180 /30Days | $1,177.71 |
Browse Plan Formulary |
Humana Gold Plus H6622-019 (HMO)
|
$87.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | P Q:60 /30Days | $1,236.49 |
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 |
PrimeTime Health Plan Plus (HMO-POS)
|
$89.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $1,194.89 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$98.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days | $1,202.19 |
Browse Plan Formulary |
MedMutual Advantage Plus (HMO)
|
$99.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days | $1,160.04 |
Browse Plan Formulary |
MedMutual Advantage Plus (HMO)
|
$99.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days | $1,199.56 |
Browse Plan Formulary |
AARP MedicareComplete Plan 3 (HMO)
|
$111.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | S Q:60 /30Days | $1,206.86 |
Browse Plan Formulary |
MedMutual Advantage Premium (PPO)
|
$119.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days | $1,160.04 |
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 |
MedMutual Advantage Premium (PPO)
|
$119.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | Q:60 /30Days | $1,199.56 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$120.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days | $1,202.24 |
Browse Plan Formulary |
HumanaChoice H5525-030 (PPO)
|
$155.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | P Q:60 /30Days | $1,235.92 |
Browse Plan Formulary |
SummaCare Medicare Emerald (HMO-POS)
|
$180.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$95.00 | $285.00 | S Q:60 /30Days | $1,143.35 |
Browse Plan Formulary |