COARTEM 20MG-120MG (24 EA ) (NDC: 00078056845)
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 6 (HMO)
|
$0.00 |
$225 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $1,311.40 |
Browse Plan Formulary |
Aetna Better Health of Ohio, MyCare Ohio (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | 0% | None | $1,309.69 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $1,294.32 |
Browse Plan Formulary |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$145 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $1,294.32 |
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 | $1,330.01 |
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 Essential (HMO)
|
$0.00 |
$60 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $1,231.82 |
Browse Plan Formulary |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $1,231.82 |
Browse Plan Formulary |
Bright Advantage (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,317.25 |
Browse Plan Formulary |
Bright Advantage Flex (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,317.25 |
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 | None | $1,313.21 |
Browse Plan Formulary |
Humana Gold Plus - Diabetes and Heart (HMO SNP)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:24 /30Days | $1,269.85 |
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 H6622-021 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:24 /30Days | $1,269.85 |
Browse Plan Formulary |
Humana Gold Plus H6622-021 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:24 /30Days | $1,269.85 |
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 | Q:24 /30Days | $1,269.85 |
Browse Plan Formulary |
MediGold Southwest OH Essential Care (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $1,307.55 |
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 | None | $1,233.46 |
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 | None | $1,233.46 |
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 |
MeridianCare Enhanced (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $1,245.69 |
Browse Plan Formulary |
MeridianCare Essential (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $1,245.69 |
Browse Plan Formulary |
MeridianCare Essential Smile (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $1,245.69 |
Browse Plan Formulary |
Molina Dual Options ? MyCareOhio (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Brand Drugs |
0% | 0% | None | $1,314.24 |
Browse Plan Formulary |
Mutual of Omaha CareAdvantage Complete (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $115.00 | None | $1,233.46 |
Browse Plan Formulary |
Humana Gold Plus H6622-055 (HMO)
|
$15.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:24 /30Days | $1,269.85 |
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 H5216-109 (PPO)
|
$19.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:24 /30Days | $1,269.85 |
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 | None | $1,294.32 |
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% | None | $1,311.40 |
Browse Plan Formulary |
HumanaChoice R5495-002 (Regional PPO)
|
$26.40 |
$395 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:24 /30Days | $1,269.85 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$28.00 |
$170 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $1,311.40 |
Browse Plan Formulary |
Mutual of Omaha CareAdvantage Plus (HMO)
|
$29.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $115.00 | None | $1,233.46 |
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 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 | Q:24 /30Days | $1,269.85 |
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 | $1,314.24 |
Browse Plan Formulary |
Anthem MediBlue Dual Advantage (HMO SNP)
|
$32.90 |
$415 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,231.82 |
Browse Plan Formulary |
Anthem MediBlue Extra (HMO)
|
$32.90 |
$415 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,231.82 |
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 | None | $1,313.21 |
Browse Plan Formulary |
MeridianCare Extra (HMO SNP)
|
$32.90 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | 25% | None | $1,245.69 |
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 |
MeridianCare Extra Smile (HMO SNP)
|
$32.90 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | 25% | None | $1,245.69 |
Browse Plan Formulary |
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% | None | $1,311.40 |
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% | None | $1,311.40 |
Browse Plan Formulary |
Bright Advantage Plus (HMO)
|
$33.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,317.25 |
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 | None | $1,233.46 |
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 | None | $1,233.46 |
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 |
MedMutual Advantage Select (PPO)
|
$38.00 |
$160 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $110.00 | None | $1,233.46 |
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 | None | $1,233.46 |
Browse Plan Formulary |
Aetna Medicare OH Connect Gold (Regional PPO)
|
$53.30 |
$0 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $1,294.32 |
Browse Plan Formulary |
Anthem MediBlue Access (PPO)
|
$56.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $1,231.82 |
Browse Plan Formulary |
Anthem MediBlue Access (PPO)
|
$56.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $1,231.82 |
Browse Plan Formulary |
Bright Advantage Flex Plus (PPO)
|
$56.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $1,317.25 |
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 H5216-023 (PPO)
|
$57.00 |
$175 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:24 /30Days | $1,269.85 |
Browse Plan Formulary |
MediGold Flexible Choice (PPO)
|
$57.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $1,307.55 |
Browse Plan Formulary |
Anthem MediBlue Access Basic (Regional PPO)
|
$57.80 |
$200 |
to be determined |
4 |
Non-Preferred Drug |
41% | 41% | None | $1,231.82 |
Browse Plan Formulary |
Anthem MediBlue Plus (HMO)
|
$63.00 |
$60 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $1,231.82 |
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 | None | $1,313.21 |
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 | None | $1,233.46 |
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 |
MedMutual Advantage Preferred (PPO)
|
$74.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $110.00 | None | $1,233.46 |
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 | Q:24 /30Days | $1,269.85 |
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 | None | $1,294.32 |
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 | None | $1,233.46 |
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 | None | $1,233.46 |
Browse Plan Formulary |
Humana Gold Choice H8145-032 (PFFS)
|
$103.00 |
$225 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:24 /30Days | $1,269.85 |
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 |
AARP MedicareComplete Plan 3 (HMO)
|
$111.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $1,311.40 |
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 | None | $1,233.46 |
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 | None | $1,233.46 |
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 | None | $1,294.32 |
Browse Plan Formulary |
MediGold Southwest OH Classic Preferred (HMO)
|
$120.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$75.00 | $150.00 | None | $1,307.55 |
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 | Q:24 /30Days | $1,269.85 |
Browse Plan Formulary |