JARDIANCE 10 MG TABLET (30.000 EA ) (NDC: 00597015230)
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 | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $523.63 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$95 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $136.00 | Q:60 /30Days | $503.56 |
Browse Plan Formulary |
Allwell Medicare (HMO)
|
$0.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$37.00 | $111.00 | None | $502.04 |
Browse Plan Formulary |
Anthem MediBlue Essential (HMO)
|
$0.00 |
$60 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | Q:30 /30Days | $484.43 |
Browse Plan Formulary |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | Q:30 /30Days | $484.35 |
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 |
Anthem MediBlue Prime Select (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | Q:30 /30Days | $485.60 |
Browse Plan Formulary |
CareSource Advantage Zero Premium (HMO)
|
$0.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $117.50 | Q:60 /30Days | $487.26 |
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 | $487.23 |
Browse Plan Formulary |
Humana Cleveland Clinic Preferred (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $518.03 |
Browse Plan Formulary |
Humana Gold Plus H6622-014 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $517.97 |
Browse Plan Formulary |
HumanaChoice H5525-042 (PPO)
|
$0.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $517.97 |
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. | 3 |
Preferred Brand |
$42.00 | $110.00 | Q:30 /30Days | $482.22 |
Browse Plan Formulary |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$160 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $110.00 | Q:30 /30Days | $483.04 |
Browse Plan Formulary |
Paramount Elite - Standard Medical and Drug (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days | $487.26 |
Browse Plan Formulary |
PrimeTime Health Plan Aultimate (HMO-POS)
|
$0.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $135.00 | None | $483.38 |
Browse Plan Formulary |
SummaCare Medicare Topaz (HMO)
|
$0.00 |
$150 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $117.50 | S Q:30 /30Days | $479.08 |
Browse Plan Formulary |
The Health Plan SecureCare - Option IV (HMO)
|
$0.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$35.00 | $70.00 | Q:30 /30Days | $482.27 |
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 Connected for MyCareOhio (Medicare-Medicaid Plan)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Brand Drugs |
0% | 0% | Q:30 /30Days | $523.42 |
Browse Plan Formulary |
HumanaChoice H5216-106 (PPO)
|
$15.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $518.00 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
|
$18.00 |
$170* | Yes, but No Gap Coverage for this drug. | 3* |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days | $523.63 |
Browse Plan Formulary |
Aetna Medicare OH Connect Gold 2 (Regional PPO)
|
$21.50 |
$350 | to be determined | 3 |
Preferred Brand |
$47.00 | $136.00 | Q:60 /30Days | $503.71 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$25.60 |
$415 | No additional gap coverage, only the Donut Hole Discount | 3 |
All Formulary Drugs |
15% | 15% | Q:30 /30Days | $523.82 |
Browse Plan Formulary |
HumanaChoice R5495-002 (Regional PPO)
|
$26.40 |
$395 | to be determined | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $517.97 |
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 |
Paramount Elite - Prime Medical and Drug (HMO)
|
$28.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days | $487.26 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H6622-015 (HMO SNP)
|
$31.20 |
$250 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $517.95 |
Browse Plan Formulary |
Aetna Better Health of Ohio Dual Preferred (HMO SNP)
|
$32.10 |
$220 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $136.00 | Q:60 /30Days | $503.60 |
Browse Plan Formulary |
Allwell Dual Medicare (HMO SNP)
|
$32.90 |
$50 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $487.30 |
Browse Plan Formulary |
Anthem MediBlue Dual Advantage (HMO SNP)
|
$32.90 |
$415 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $484.35 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$32.90 |
$415 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $484.35 |
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 |
CareSource Advantage (HMO)
|
$32.90 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $117.50 | Q:60 /30Days | $487.26 |
Browse Plan Formulary |
Gateway Health Medicare Assured Diamond (HMO SNP)
|
$32.90 |
$415 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $485.50 |
Browse Plan Formulary |
Gateway Health Medicare Assured Ruby (HMO SNP)
|
$32.90 |
$415 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | Q:30 /30Days | $485.50 |
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% | S | $506.77 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 1 (PPO SNP)
|
$32.90 |
$415 | No additional gap coverage, only the Donut Hole Discount | 3 |
All Formulary Drugs |
25% | 25% | Q:30 /30Days | $523.74 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 2 (PPO SNP)
|
$32.90 |
$415 | No additional gap coverage, only the Donut Hole Discount | 3 |
All Formulary Drugs |
25% | 25% | Q:30 /30Days | $523.97 |
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 SNP (HMO SNP)
|
$36.70 |
$415 | No additional gap coverage, only the Donut Hole Discount | 3 |
All Formulary Drugs |
15% | 15% | Q:30 /30Days | $480.80 |
Browse Plan Formulary |
MedMutual Advantage Choice (HMO)
|
$38.00 |
$55 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $110.00 | Q:30 /30Days | $483.04 |
Browse Plan Formulary |
MedMutual Advantage Choice (HMO)
|
$38.00 |
$55 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $110.00 | Q:30 /30Days | $482.22 |
Browse Plan Formulary |
MedMutual Advantage Select (PPO)
|
$38.00 |
$160 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $110.00 | Q:30 /30Days | $483.04 |
Browse Plan Formulary |
MedMutual Advantage Select (PPO)
|
$38.00 |
$160 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $110.00 | Q:30 /30Days | $482.22 |
Browse Plan Formulary |
PrimeTime Health Plan Classic (HMO-POS)
|
$39.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $125.00 | None | $483.38 |
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)
|
$43.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $117.50 | S Q:30 /30Days | $479.08 |
Browse Plan Formulary |
The Health Plan SecureCare - Option II (HMO)
|
$46.00 |
$100 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$35.00 | $70.00 | Q:30 /30Days | $482.27 |
Browse Plan Formulary |
Aetna Medicare OH Connect Gold (Regional PPO)
|
$53.30 |
$0 | to be determined | 3 |
Preferred Brand |
$47.00 | $136.00 | Q:60 /30Days | $503.71 |
Browse Plan Formulary |
Anthem MediBlue Access Basic (Regional PPO)
|
$57.80 |
$200 | to be determined | 3 |
Preferred Brand |
$42.00 | $84.00 | Q:30 /30Days | $484.35 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$63.00 |
$60 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | Q:30 /30Days | $484.47 |
Browse Plan Formulary |
The Health Plan SecureChoice - Option II (PPO)
|
$66.00 |
$100 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$35.00 | $70.00 | Q:30 /30Days | $482.27 |
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 Advantage Plus (HMO)
|
$67.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $117.50 | Q:60 /30Days | $487.26 |
Browse Plan Formulary |
Anthem MediBlue Access (PPO)
|
$68.00 |
$50 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | Q:30 /30Days | $484.42 |
Browse Plan Formulary |
Anthem MediBlue Access (PPO)
|
$68.00 |
$50 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | Q:30 /30Days | $484.14 |
Browse Plan Formulary |
Paramount Elite - Enhanced Medical and Drug (HMO)
|
$68.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $90.00 | Q:60 /30Days | $487.26 |
Browse Plan Formulary |
MedMutual Advantage Preferred (PPO)
|
$74.00 |
$55 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $110.00 | Q:30 /30Days | $482.22 |
Browse Plan Formulary |
MedMutual Advantage Preferred (PPO)
|
$74.00 |
$55 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $110.00 | Q:30 /30Days | $483.04 |
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 |
HumanaChoice H5216-024 (PPO)
|
$75.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $518.03 |
Browse Plan Formulary |
SummaCare Medicare Sapphire (HMO-POS)
|
$76.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $117.50 | S Q:30 /30Days | $479.08 |
Browse Plan Formulary |
Anthem MediBlue Access Plus (PPO)
|
$87.00 |
$40 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $84.00 | Q:30 /30Days | $485.08 |
Browse Plan Formulary |
Humana Gold Plus H6622-019 (HMO)
|
$87.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $517.98 |
Browse Plan Formulary |
PrimeTime Health Plan Plus (HMO-POS)
|
$89.00 |
$100 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $125.00 | None | $483.38 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$98.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $136.00 | Q:60 /30Days | $503.58 |
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 Plus (HMO)
|
$99.00 |
$55 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $110.00 | Q:30 /30Days | $483.04 |
Browse Plan Formulary |
MedMutual Advantage Plus (HMO)
|
$99.00 |
$55 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $110.00 | Q:30 /30Days | $482.22 |
Browse Plan Formulary |
AARP MedicareComplete Plan 3 (HMO)
|
$111.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $125.00 | Q:30 /30Days | $523.60 |
Browse Plan Formulary |
MedMutual Advantage Premium (PPO)
|
$119.00 |
$55 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $110.00 | Q:30 /30Days | $483.04 |
Browse Plan Formulary |
MedMutual Advantage Premium (PPO)
|
$119.00 |
$55 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $110.00 | Q:30 /30Days | $482.22 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$120.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $136.00 | Q:60 /30Days | $503.58 |
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 H5525-030 (PPO)
|
$155.00 |
$100 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | Q:30 /30Days | $517.98 |
Browse Plan Formulary |
SummaCare Medicare Emerald (HMO-POS)
|
$180.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $112.50 | S Q:30 /30Days | $479.08 |
Browse Plan Formulary |