SAPHRIS 10 MG TAB SL BLK CHERY (60.000 EA ) (NDC: 00456241060)
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 |
5 |
Specialty Tier |
28% | 28% | Q:60 /30Days | $1,239.07 |
Browse Plan Formulary |
Advantra Silver (PPO)
|
$0.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:60 /30Days | $1,225.33 |
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 | $1,225.25 |
Browse Plan Formulary |
Allwell Medicare (HMO)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | None | $1,223.67 |
Browse Plan Formulary |
Anthem MediBlue Essential (HMO)
|
$0.00 |
$60 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
31% | n/a | Q:60 /30Days | $1,196.17 |
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 Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $1,195.82 |
Browse Plan Formulary |
Anthem MediBlue Prime Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | Q:60 /30Days | $1,192.93 |
Browse Plan Formulary |
Buckeye Health Plan - MyCare Ohio (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | 0% | None | $1,186.03 |
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 | $1,186.04 |
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 | $1,186.00 |
Browse Plan Formulary |
Humana Cleveland Clinic Preferred (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
33% | n/a | P Q:60 /30Days | $1,261.39 |
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 H6622-022 (HMO)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:60 /30Days | $1,261.39 |
Browse Plan Formulary |
HumanaChoice H5525-042 (PPO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | P Q:60 /30Days | $1,261.45 |
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:60 /30Days | $1,177.28 |
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:60 /30Days | $1,195.40 |
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 | $1,209.22 |
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 | $1,186.04 |
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 |
SummaCare Medicare Topaz (HMO)
|
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
5* |
Specialty Tier |
30% | n/a | S Q:60 /30Days | $1,166.37 |
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% | Q:60 /30Days | $1,237.64 |
Browse Plan Formulary |
HumanaChoice H5216-106 (PPO)
|
$15.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:60 /30Days | $1,261.39 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
|
$18.00 |
$170 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
29% | 29% | Q:60 /30Days | $1,239.07 |
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 | $1,225.43 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO-POS SNP)
|
$25.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
5 |
All Formulary Drugs |
15% | 15% | Q:60 /30Days | $1,258.76 |
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 |
HumanaChoice R5495-002 (Regional PPO)
|
$26.40 |
$395 |
to be determined |
5 |
Specialty Tier |
25% | n/a | P Q:60 /30Days | $1,261.45 |
Browse Plan Formulary |
UnitedHealthcare Assisted Living Plan (HMO-POS SNP)
|
$27.50 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | 29% | Q:60 /30Days | $1,245.40 |
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 | $1,186.04 |
Browse Plan Formulary |
Allwell Dual Medicare (HMO SNP)
|
$32.90 |
$50 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
32% | n/a | None | $1,186.30 |
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 | Q:60 /30Days | $1,195.82 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$32.90 |
$415 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
25% | n/a | Q:60 /30Days | $1,195.82 |
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 |
4 |
Non-Preferred Drug |
$100.00 | $250.00 | Q:60 /30Days | $1,186.04 |
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 | Q:60 /30Days | $1,182.13 |
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 | Q:60 /30Days | $1,182.13 |
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 | $1,209.22 |
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 | $1,226.32 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO-POS SNP)
|
$32.90 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
5 |
All Formulary Drugs |
25% | 25% | Q:60 /30Days | $1,253.26 |
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 2 (PPO SNP)
|
$32.90 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
5 |
All Formulary Drugs |
25% | 25% | Q:60 /30Days | $1,249.88 |
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:60 /30Days | $1,177.28 |
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:60 /30Days | $1,195.40 |
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:60 /30Days | $1,177.28 |
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:60 /30Days | $1,195.40 |
Browse Plan Formulary |
SummaCare Medicare Ruby (HMO)
|
$43.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | S Q:60 /30Days | $1,166.37 |
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 H6622-011 (HMO)
|
$46.00 |
$195 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
29% | n/a | P Q:60 /30Days | $1,261.39 |
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 | $1,225.43 |
Browse Plan Formulary |
Anthem MediBlue Access Basic (Regional PPO)
|
$57.80 |
$200 |
to be determined |
5 |
Specialty Tier |
29% | n/a | Q:60 /30Days | $1,195.82 |
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 | $1,186.04 |
Browse Plan Formulary |
Anthem MediBlue Access (PPO)
|
$68.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
32% | n/a | Q:60 /30Days | $1,191.59 |
Browse Plan Formulary |
Anthem MediBlue Access (PPO)
|
$68.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
32% | n/a | Q:60 /30Days | $1,195.81 |
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 - 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 | $1,186.04 |
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:60 /30Days | $1,177.28 |
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:60 /30Days | $1,195.40 |
Browse Plan Formulary |
HumanaChoice H5216-024 (PPO)
|
$75.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
28% | n/a | P Q:60 /30Days | $1,261.39 |
Browse Plan Formulary |
SummaCare Medicare Sapphire (HMO-POS)
|
$76.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | S Q:60 /30Days | $1,166.37 |
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 | Q:60 /30Days | $1,192.46 |
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 H6622-019 (HMO)
|
$87.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
30% | n/a | P Q:60 /30Days | $1,261.25 |
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 | $1,225.34 |
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:60 /30Days | $1,177.28 |
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:60 /30Days | $1,195.40 |
Browse Plan Formulary |
AARP MedicareComplete Plan 3 (HMO)
|
$111.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | 33% | Q:60 /30Days | $1,240.24 |
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:60 /30Days | $1,177.28 |
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 |
MedMutual Advantage Premium (PPO)
|
$119.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $110.00 | Q:60 /30Days | $1,195.40 |
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 | $1,225.33 |
Browse Plan Formulary |
HumanaChoice H5525-030 (PPO)
|
$155.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Specialty Tier |
31% | n/a | P Q:60 /30Days | $1,261.45 |
Browse Plan Formulary |
SummaCare Medicare Emerald (HMO-POS)
|
$180.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
5 |
Specialty Tier |
33% | n/a | S Q:60 /30Days | $1,166.37 |
Browse Plan Formulary |