State PDP Region Organizatio Plan Name Drug Plan Drug No Offers Type of
n Name Premium 1 Deductible Premium Variable Extra
with Full Copayment Coverage
Low s Offered in
Income (Tiers) the Gap
Subsidy (G=generics;
Aetna
Medicare
Aetna Rx
Ohio 14 Medicare Essentials $31.13 $250
Aetna
Aetna Medicare
Ohio 14 Medicare Rx Plus $41.35 $0 G
Aetna
Medicare
Aetna Rx
Ohio 14 Medicare Premier $56.69 $0 G
AmeriHeal
AmeriHeal th
th Advantag
Advantag e Rx
Ohio 14 e Option l $22.14 $250
Anthem
Blue
Cross and Blue
Blue Medicare
Ohio 14 Shield Rx Value $20.90 $250
Anthem
Blue
Cross and Blue
Blue Medicare
Ohio 14 Shield Rx Plus $29.08 $0
Anthem
Blue Blue
Cross and Medicare
Blue Rx
Ohio 14 Shield Premier $36.87 $0 G
CIGNATU
CIGNA RE Rx
HealthCar Value
Ohio 14 e Plan $34.82 $250
CIGNA CIGNATU
HealthCar RE Rx
Ohio 14 e Plus Plan $40.03 $0
CIGNATU
CIGNA RE Rx
HealthCar Complete
Ohio 14 e Plan $47.97 $0 G
Coventry
AdvantraR AdvantraR
Ohio 14 x x Value $21.28 $0
Coventry
AdvantraR AdvantraR
Ohio 14 x x Premier $31.92 $0
Coventry AdvantraR
AdvantraR x Premier
Ohio 14 x Plus $44.59 $0
First First
Health Health
Ohio 14 Premier Premier $25.54 $250
Humana
PDP
Standard
Humana S5884-
Ohio 14 Inc. 072 $14.43 $250
Humana
PDP
Enhanced
Humana S5884-
Ohio 14 Inc. 012 $18.43 $0
Humana
PDP
Complete
Humana S5884-
Ohio 14 Inc. 042 $63.91 $0 G/B
Prescripti
Marquette on
National Pathway
Life Silver
Insurance Plan Reg
Ohio 14 Company 14 $40.23 $250
Marquette Prescripti
National on
Life Pathway
Insurance Gold Plan
Ohio 14 Company Reg 14 $51.47 $0
Prescripti
Marquette on
National Pathway
Life Platinum
Insurance Plan Reg
Ohio 14 Company 14 $68.05 $0
Medco
Health
Solutions, YOURx
Ohio 14 Inc. PLAN $31.64 $250
Communit
MEMBER y Care Rx
Ohio 14 HEALTH BASIC $30.79 $250
Communit
MEMBER y Care Rx
Ohio 14 HEALTH CHOICE $38.87 $250
Communit
MEMBER y Care Rx
Ohio 14 HEALTH GOLD $42.77 $100
PacifiCare
Life and
Health PacifiCare
Insurance Saver
Ohio 14 Company Plan $25.20 $0
PacifiCare
Life and
Health PacifiCare
Insurance Select
Ohio 14 Company Plan $39.60 $0
PacifiCare
Life and
Health PacifiCare
Insurance Comprehe
Ohio 14 Company nsive Plan $44.54 $0 G
Paramoun
t
Prescripti Paramoun
on Drug t Drug
Ohio 14 Plan Plan $50.21 $250
Prescripti
on
Pennsylva Pathway
nia Life Bronze
Insurance Plan Reg
Ohio 14 Company 14 $30.80 $250
Prescripti
on
Pennsylva Pathway
nia Life Silver
Insurance Plan
Ohio 14 Company Reg14 $40.15 $250
Prescripti
Pennsylva on
nia Life Pathway
Insurance Gold Plan
Ohio 14 Company Reg 14 $51.41 $0
SilverScri SilverScri
Ohio 14 pt pt $29.99 $250
SilverScri SilverScri
Ohio 14 pt pt Plus $59.04 $100
Sterling Sterling
Prescripti Prescripti
on Drug on Drug
Ohio 14 Plan Plan $53.80 $100
Medicare
Rx
Ohio 14 Unicare Rewards $20.90 $250
Medicare
Rx
Rewards
Ohio 14 Unicare Plus $29.08 $0
Medicare
Rx
Rewards
Ohio 14 Unicare Premier $39.31 $0 G
UA
Medicare
United Part D
American Prescripti
Insurance on Drug
Ohio 14 Company Cov $35.00 $0
United AARP
Healthcar Medicare
Ohio 14 e Rx Plan $27.93 $0
United
United Medicare
Healthcar MedAdva
Ohio 14 e nce $30.06 $0
WellCare
Ohio 14 WellCare Signature $19.96 $0
WellCare
Ohio 14 WellCare Complete $41.56 $0
WellCare
Ohio 14 WellCare Premier $45.05 $0
Sources: CMS PDP Landscape of Local Plans Source File
Number of Number of Number of Mail Order contract # plan # segement # formulary benefit_type
Top 100 Top 100 Top 100 Offered
Drugs on Drugs Drugs with
Formulary 2 Requiring Cost
Prior Sharing
Authorizati below $20 2
86 5 54 S5810 048 0 2662 Actuarially Equivalent Standard
86 5 54 S5810 150 0 2662 Enhanced Alternative
100 38 78 S5810 184 0 2681 Enhanced Alternative
92 13 N/A S5783 006 0 3416 Defined Standard Benefit
92 5 56 S5596 013 0 2493 Actuarially Equivalent Standard
92 5 56 S5596 014 0 2493 Enhanced Alternative
98 5 57 S5596 015 0 2546 Enhanced Alternative
99 31 86 S5617 068 0 1241 Actuarially Equivalent Standard
99 31 57 S5617 070 0 1241 Enhanced Alternative
99 31 57 S5617 184 0 1241 Enhanced Alternative
78 9 57 S5670 075 0 2764 Enhanced Alternative
100 12 77 S5670 076 0 2759 Enhanced Alternative
100 12 22 S5670 078 0 2766 Basic Alternative
100 12 N/A S5768 017 0 1727 Defined Standard Benefit
99 8 N/A S5884 072 0 1863 Defined Standard Benefit
99 8 56 S5884 012 0 1863 Enhanced Alternative
99 8 56 S5884 042 0 1863 Enhanced Alternative
92 1 57 S5581 126 0 1446 Actuarially Equivalent Standard
92 1 57 S5581 030 0 1446 Enhanced Alternative
100 0 57 S5581 054 0 1494 Enhanced Alternative
98 10 95 S5660 014 0 3164 Basic Alternative
95 10 58 S5803 083 0 3422 Actuarially Equivalent Standard
95 10 91 S5803 151 0 3422 Actuarially Equivalent Standard
95 10 58 S5803 117 0 3422 Enhanced Alternative
78 9 53 S5921 052 0 2654 Basic Alternative
87 3 54 S5921 051 0 2656 Basic Alternative
78 9 53 S5921 053 0 2654 Enhanced Alternative
95 25 N/A S5588 001 0 3004 Defined Standard Benefit
92 1 N/A S5597 079 0 1446 Defined Standard Benefit
92 1 57 S5597 178 0 1446 Actuarially Equivalent Standard
92 1 57 S5597 046 0 1446 Enhanced Alternative
92 5 92 S5601 028 0 897 Actuarially Equivalent Standard
98 5 56 S5601 029 0 619 Basic Alternative
98 5 56 S4802 026 0 3245 Basic Alternative
92 5 56 S5960 014 0 2493 Actuarially Equivalent Standard
92 5 56 S5960 050 0 2493 Enhanced Alternative
98 5 57 S5960 084 0 2546 Enhanced Alternative
99 10 58 S5755 017 0 3296 Basic Alternative
100 2 58 S5820 013 0 3440 Basic Alternative
100 2 58 S5820 117 0 3440 Basic Alternative
88 12 56 S5967 048 0 2366 Basic Alternative
85 9 74 S5967 082 0 2003 Enhanced Alternative
85 9 56 S5967 117 0 2629 Enhanced Alternative
icl_amount STCD
2250 OH
2250 OH
2250 OH
2250 OH
2250 OH
2250 OH
2250 OH
2250 OH
2250 OH
2250 OH
2250 OH
2250 OH
2250 OH
2250 OH
2250 OH
2250 OH
0 OH
2250 OH
2000 OH
2000 OH
2250 OH
2250 OH
2250 OH
2250 OH
2250 OH
2250 OH
2250 OH
2250 OH
2250 OH
2250 OH
2000 OH
2250 OH
2250 OH
2250 OH
2250 OH
2250 OH
2250 OH
2250 OH
2250 OH
2250 OH
2250 OH
1850 OH
2250 OH