HYDROCODONE-IBUPROFEN 5-200 MG (100.000 EA ) (NDC: 53746014601)
2022 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 |
Aetna Medicare Premier (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:150 /30Days | $513.00 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO-POS)
|
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $141.00 | Q:150 /30Days | $513.00 |
Browse Plan Formulary |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $141.00 | Q:150 /30Days | $513.00 |
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:50 /10Days | $295.20 |
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:50 /10Days | $379.80 |
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. |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:50 /10Days | $363.60 |
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:50 /10Days | $343.80 |
Browse Plan Formulary |
Anthem MediBlue Prime Select (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:50 /10Days | $302.40 |
Browse Plan Formulary |
CareSource Advantage Zero Premium (HMO)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:50 /30Days | $478.80 |
Browse Plan Formulary |
CareSource MyCare Ohio (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
All Generics, All Brands |
1 |
Tier 1 |
0% | 0% | Q:50 /30Days | $428.40 |
Browse Plan Formulary |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:50 /30Days | $531.00 |
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 |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:50 /30Days | $531.00 |
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 | Q:150 /30Days | $460.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
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 | Q:150 /30Days | $462.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5216-285 (PPO)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:150 /30Days | $462.60 |
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:150 /30Days | $462.60 |
Browse Plan Formulary |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $110.00 | Q:50 /30Days | $439.20 |
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 |
$95 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $110.00 | Q:50 /30Days | $460.80 |
Browse Plan Formulary |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $110.00 | Q:50 /30Days | $442.80 |
Browse Plan Formulary |
PrimeTime Health Plan Aultimate (HMO-POS)
|
$0.00 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | $45.00 | None | $522.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SummaCare Medicare Topaz (HMO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:150 /30Days | $450.00 |
Browse Plan Formulary |
HumanaChoice H5216-106 (PPO)
|
$15.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:150 /30Days | $460.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$16.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:150 /30Days | $460.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
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 Plus (HMO)
|
$19.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:50 /10Days | $311.40 |
Browse Plan Formulary |
Humana Gold Plus H6622-070 (HMO)
|
$21.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:150 /30Days | $462.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Anthem MediBlue Extra (HMO)
|
$22.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:50 /10Days | $320.40 |
Browse Plan Formulary |
MedMutual Advantage Secure (HMO)
|
$22.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $110.00 | Q:50 /30Days | $439.20 |
Browse Plan Formulary |
MedMutual Advantage Secure (HMO)
|
$22.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $110.00 | Q:50 /30Days | $442.80 |
Browse Plan Formulary |
Aetna Medicare Assure 1 (HMO D-SNP)
|
$23.20 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:150 /30Days | $513.00 |
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)
|
$25.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | Q:50 /30Days | $478.80 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H6622-015 (HMO D-SNP)
|
$27.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:150 /30Days | $460.80 |
Browse Plan Formulary |
Perennial Advantage Strive (HMO I-SNP)
|
$28.20 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | Q:480 /30Days | $597.60 |
Browse Plan Formulary |
SummaCare Medicare Garnet (HMO)
|
$29.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:150 /30Days | $450.00 |
Browse Plan Formulary |
SummaCare Medicare Garnet (HMO)
|
$29.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:150 /30Days | $450.00 |
Browse Plan Formulary |
Perennial Advantage Concierge (HMO C-SNP)
|
$31.30 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $45.00 | Q:480 /30Days | $597.60 |
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 |
Aetna Medicare Premier Plus 2 (Regional PPO)
|
$33.40 |
$260 |
No |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:150 /30Days | $513.00 |
Browse Plan Formulary |
Anthem MediBlue Dual Advantage (HMO D-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:50 /10Days | $320.40 |
Browse Plan Formulary |
CareSource Dual Advantage (HMO D-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | 25% | Q:50 /30Days | $478.80 |
Browse Plan Formulary |
CommuniCare Advantage ISNP (HMO I-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $540.00 |
Browse Plan Formulary |
CommuniCare Advantage ISNP (HMO I-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $541.80 |
Browse Plan Formulary |
CommuniCare Advantage ISNP (HMO I-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $543.60 |
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 |
Valor Health Plan (HMO I-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $543.60 |
Browse Plan Formulary |
PrimeTime Health Plan Classic (HMO-POS)
|
$39.00 |
$150* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$8.00 | $20.00 | None | $522.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MedMutual Advantage Choice (HMO)
|
$40.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $110.00 | Q:50 /30Days | $439.20 |
Browse Plan Formulary |
MedMutual Advantage Choice (HMO)
|
$40.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $110.00 | Q:50 /30Days | $460.80 |
Browse Plan Formulary |
MedMutual Advantage Choice (HMO)
|
$40.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $110.00 | Q:50 /30Days | $442.80 |
Browse Plan Formulary |
Anthem MediBlue Access Basic (Regional PPO)
|
$41.50 |
$200 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:50 /10Days | $320.40 |
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. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:150 /30Days | $450.00 |
Browse Plan Formulary |
MedMutual Advantage Select (PPO)
|
$44.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $110.00 | Q:50 /30Days | $442.80 |
Browse Plan Formulary |
MedMutual Advantage Select (PPO)
|
$44.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $110.00 | Q:50 /30Days | $439.20 |
Browse Plan Formulary |
MedMutual Advantage Select (PPO)
|
$44.00 |
$95 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $110.00 | Q:50 /30Days | $460.80 |
Browse Plan Formulary |
Aetna Medicare Premier Plus 1 (Regional PPO)
|
$44.50 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | Q:150 /30Days | $513.00 |
Browse Plan Formulary |
HumanaChoice R5495-002 (Regional PPO)
|
$47.80 |
$480 |
No |
4 |
Non-Preferred Drug |
20% | 20% | Q:150 /30Days | $462.60 |
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)
|
$55.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$37.00 | $74.00 | Q:50 /10Days | $347.40 |
Browse Plan Formulary |
Anthem MediBlue Access (PPO)
|
$56.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:50 /10Days | $320.40 |
Browse Plan Formulary |
Paramount Elite Enhanced (HMO)
|
$68.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$15.00 | $30.00 | Q:150 /30Days | $480.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5216-024 (PPO)
|
$76.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | Q:150 /30Days | $460.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
SummaCare Medicare Sapphire (HMO-POS)
|
$76.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | Q:150 /30Days | $450.00 |
Browse Plan Formulary |
MedMutual Advantage Preferred (PPO)
|
$80.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $110.00 | Q:50 /30Days | $439.20 |
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)
|
$80.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $110.00 | Q:50 /30Days | $460.80 |
Browse Plan Formulary |
MedMutual Advantage Preferred (PPO)
|
$80.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $110.00 | Q:50 /30Days | $442.80 |
Browse Plan Formulary |
Anthem MediBlue Access Plus (PPO)
|
$89.00 |
$40 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $84.00 | Q:50 /10Days | $324.00 |
Browse Plan Formulary |
PrimeTime Health Plan Plus (HMO-POS)
|
$89.00 |
$100* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$8.00 | $20.00 | None | $522.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H6622-019 (HMO)
|
$91.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:150 /30Days | $460.80 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MedMutual Advantage Plus (HMO)
|
$97.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $110.00 | Q:50 /30Days | $460.80 |
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)
|
$97.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $110.00 | Q:50 /30Days | $442.80 |
Browse Plan Formulary |
MedMutual Advantage Plus (HMO)
|
$97.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $110.00 | Q:50 /30Days | $439.20 |
Browse Plan Formulary |
Aetna Medicare Premier 2 (PPO)
|
$118.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | Q:150 /30Days | $513.00 |
Browse Plan Formulary |
MedMutual Advantage Premium (PPO)
|
$134.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $110.00 | Q:50 /30Days | $439.20 |
Browse Plan Formulary |
MedMutual Advantage Premium (PPO)
|
$134.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $110.00 | Q:50 /30Days | $460.80 |
Browse Plan Formulary |
MedMutual Advantage Premium (PPO)
|
$134.00 |
$55 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $110.00 | Q:50 /30Days | $442.80 |
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 |
Aetna Medicare Premier 1 (PPO)
|
$149.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $141.00 | Q:150 /30Days | $513.00 |
Browse Plan Formulary |
HumanaChoice H5525-030 (PPO)
|
$151.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$97.00 | $281.00 | Q:150 /30Days | $462.60 |
Browse Plan Formulary |
SummaCare Medicare Emerald (HMO-POS)
|
$180.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | Q:150 /30Days | $450.00 |
Browse Plan Formulary |