CLORAZEPATE 3.75 MG TABLET (100.000 EA ) (NDC: 00378003001)
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 |
2* |
Generic |
$12.00 | $0.00 | Q:720 /30Days | $126.43 |
Browse Plan Formulary |
Aetna Better Health of Ohio, MyCare Ohio (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | 0% | P Q:180 /30Days | $138.08 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $136.00 | Q:90 /30Days | $74.44 |
Browse Plan Formulary |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$145 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $136.00 | Q:90 /30Days | $73.53 |
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 | $97.94 |
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. |
3 |
Preferred Brand |
$42.00 | $84.00 | None | $91.48 |
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 | None | $91.94 |
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 | P Q:180 /30Days | $137.83 |
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 | P Q:180 /30Days | $137.83 |
Browse Plan Formulary |
CareSource Advantage Zero Premium (HMO)
|
$0.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | $37.50 | P Q:180 /30Days | $55.36 |
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 | None | $80.91 |
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 | None | $80.88 |
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 | None | $80.98 |
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 | None | $81.33 |
Browse Plan Formulary |
MediGold Southwest OH Essential Care (HMO)
|
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$18.00 | $36.00 | P Q:180 /30Days | $137.59 |
Browse Plan Formulary |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$160* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$15.00 | $35.00 | P Q:90 /30Days | $109.09 |
Browse Plan Formulary |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$160* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$15.00 | $35.00 | P Q:90 /30Days | $111.28 |
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 |
MeridianCare Enhanced (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $60.00 | None | $79.90 |
Browse Plan Formulary |
MeridianCare Essential (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $20.00 | None | $79.90 |
Browse Plan Formulary |
MeridianCare Essential Smile (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $20.00 | None | $79.90 |
Browse Plan Formulary |
Molina Dual Options ? MyCareOhio (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | 0% | P Q:180 /30Days | $130.04 |
Browse Plan Formulary |
Mutual of Omaha CareAdvantage Complete (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $0.00 | P Q:90 /30Days | $117.60 |
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 | None | $80.91 |
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 | None | $81.07 |
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:90 /30Days | $74.33 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$25.60 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
2 |
All Formulary Drugs |
15% | 15% | Q:720 /30Days | $125.72 |
Browse Plan Formulary |
HumanaChoice R5495-002 (Regional PPO)
|
$26.40 |
$395 |
to be determined |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $81.33 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$28.00 |
$170* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$8.00 | $0.00 | Q:720 /30Days | $126.74 |
Browse Plan Formulary |
Mutual of Omaha CareAdvantage Plus (HMO)
|
$29.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$5.00 | $0.00 | P Q:90 /30Days | $117.57 |
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 |
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 | None | $80.95 |
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 | $97.97 |
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 | None | $91.94 |
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 | None | $91.94 |
Browse Plan Formulary |
CareSource Advantage (HMO)
|
$32.90 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $25.00 | P Q:180 /30Days | $55.36 |
Browse Plan Formulary |
MeridianCare Extra (HMO SNP)
|
$32.90 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | None | $79.90 |
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 |
2 |
Generic |
25% | 25% | None | $79.90 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 1 (PPO SNP)
|
$32.90 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
2 |
All Formulary Drugs |
25% | 25% | Q:720 /30Days | $125.67 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 2 (PPO SNP)
|
$32.90 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
2 |
All Formulary Drugs |
25% | 25% | Q:720 /30Days | $125.30 |
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 | P Q:180 /30Days | $137.83 |
Browse Plan Formulary |
MedMutual Advantage Choice (HMO)
|
$38.00 |
$55* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$10.00 | $22.00 | P Q:90 /30Days | $111.28 |
Browse Plan Formulary |
MedMutual Advantage Choice (HMO)
|
$38.00 |
$55* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$10.00 | $22.00 | P Q:90 /30Days | $109.09 |
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 |
MedMutual Advantage Select (PPO)
|
$38.00 |
$160* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$15.00 | $35.00 | P Q:90 /30Days | $111.28 |
Browse Plan Formulary |
MedMutual Advantage Select (PPO)
|
$38.00 |
$160* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$15.00 | $35.00 | P Q:90 /30Days | $109.09 |
Browse Plan Formulary |
Aetna Medicare OH Connect Gold (Regional PPO)
|
$53.30 |
$0 |
to be determined |
3 |
Preferred Brand |
$47.00 | $136.00 | Q:90 /30Days | $74.17 |
Browse Plan Formulary |
Anthem MediBlue Access (PPO)
|
$56.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | None | $92.19 |
Browse Plan Formulary |
Anthem MediBlue Access (PPO)
|
$56.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | None | $92.13 |
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 | P Q:180 /30Days | $137.83 |
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 | None | $81.12 |
Browse Plan Formulary |
MediGold Flexible Choice (PPO)
|
$57.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$18.00 | $36.00 | P Q:180 /30Days | $137.59 |
Browse Plan Formulary |
Anthem MediBlue Access Basic (Regional PPO)
|
$57.80 |
$200 |
to be determined |
3 |
Preferred Brand |
$42.00 | $84.00 | None | $91.94 |
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 | None | $89.16 |
Browse Plan Formulary |
CareSource Advantage Plus (HMO)
|
$67.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $25.00 | P Q:180 /30Days | $55.36 |
Browse Plan Formulary |
MedMutual Advantage Preferred (PPO)
|
$74.00 |
$55* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$10.00 | $22.00 | P Q:90 /30Days | $109.09 |
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 |
MedMutual Advantage Preferred (PPO)
|
$74.00 |
$55* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$10.00 | $22.00 | P Q:90 /30Days | $111.28 |
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 | None | $80.96 |
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:90 /30Days | $74.69 |
Browse Plan Formulary |
MedMutual Advantage Plus (HMO)
|
$99.00 |
$55* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$10.00 | $22.00 | P Q:90 /30Days | $109.09 |
Browse Plan Formulary |
MedMutual Advantage Plus (HMO)
|
$99.00 |
$55* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$10.00 | $22.00 | P Q:90 /30Days | $111.28 |
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 | None | $81.56 |
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. |
2 |
Generic |
$8.00 | $0.00 | Q:720 /30Days | $126.43 |
Browse Plan Formulary |
MedMutual Advantage Premium (PPO)
|
$119.00 |
$55* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$10.00 | $22.00 | P Q:90 /30Days | $111.28 |
Browse Plan Formulary |
MedMutual Advantage Premium (PPO)
|
$119.00 |
$55* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$10.00 | $22.00 | P Q:90 /30Days | $109.09 |
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:90 /30Days | $74.48 |
Browse Plan Formulary |
MediGold Southwest OH Classic Preferred (HMO)
|
$120.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$15.00 | $0.00 | P Q:180 /30Days | $137.59 |
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 | None | $81.32 |
Browse Plan Formulary |