Affordable Ohio Health Insurance Plans

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Medicare prescription drug benefits are available to qualified Ohio residents. 2023 Part D plans provide comprehensive coverage from a wide selection of carriers. To enroll in a Medicare drug plan, you must have Part A (Hospital Insurance) and Part B (Medical Insurance). If you delay enrolling for coverage, it is possible that you may incur a late-enrollment penalty without other credible coverage. Although coverage is optional, it is highly-recommended you enroll since the need for prescriptions can quickly change. Even if you are not currently prescribed medications, coverage should still be secured.

Before enrolling in a PDP plan, Buckeye State consumers should consider any other prescription benefits they have or are eligible for. Many Advantage plans offer prescription drug benefits, eliminating the need to purchase a separate policy. Parts A and B are required for an MA plan. Medical Savings Accounts (MSAs), some employer-provided plans, and private fee-for-service plans generally do not offer these benefits.

Several plans now offer substantial savings for insulin. At least one pen and dial dosage forms are offered for the different types of models. Enrollees receiving LIS (low-income cost-sharing subsidy) are not eligible for the supply copayment.Several plans offer costs less than $35. The policy deductible would apply to all other tiers, but not insulin. Medicare Supplement Plans in Ohio do not include dug coverage, so a separate plan must be purchased.

Medicare Part D Plan Coverage

All plans are required to cover specific drugs. Often, these drugs are used for treating serious or terminal diseases and conditions. “Formulary” lists are provided by all carriers, and the listing of all tiers is disclosed. Generic and brand-name drugs are included, along with specialty drugs, which typically are the most expensive. Most formulary lists include two (or more) drugs that  are in the most popular classes and prescribed categories. Throughout the year, there my be changes to the formulary list for several reasons, including newer drugs that have become available.

Drugs can also be removed from the list if the Food And Drug Administration decides the drugs are unsafe, or they are no longer offered by the manufacturer. Also, generic drug designations may replace brand name drug designations, resulting in lower out-of-pocket costs for consumers. If changes occur with a prescription you are actively taking, 30 days written notice will be provided at that time or when you refill the prescription. You can request an exception, although utilizing formulary drugs is typically the most economical option.

When initially using your plan, your Medicare card should be carried with you. It will show your name, ID number, and the date coverage began. An automatic refill service may deliver prescribed drugs to your home or business. Your contact information will need to have been previously required for verification. Also, a Medicare drug plan can be joined without forfeiting current coverage if you’re in a cost plan, fee-for-service plan (private), MSA plan, or some job-sponsored Medicare health plans.

Note: Usage of generic drugs can substantially reduce copays, regardless of which Part D you are enrolled in. As copies of brand name drugs, similarities include intended usage, quality of drug, strength, safety, prescribed dosage, and characteristics of performance. Identical active ingredients are used and FDA research and approval is always required.

2023 Defined Standard Benefits

Deductible – $505. After the deductible is paid, 25% of covered costs (to Initial Coverage Limit) are paid by the beneficiary.

Initial Coverage Limit – $4,660. Donut Hole starts when cost of retail drug exceeds the value.

Out-Of-Pocket Threshold – $7,400. All out-of-pocket costs including the donut hole.

Total Covered Spending (Including Coverage Gap) – $10,516.25. Catastrophic benefits start when this amount is reached.

Estimated Part D spending when eligible for coverage gap discount programs – $11,206.28.

Minimum cost-sharing (catastrophic coverage benefit) – $4.15 for generic/preferred and $10.35 for remaining drugs.

 

Part D Plan Rates Ohio

 

Part D Drug List Tiers

Formularies often list their drugs in “tier” classifications. Generally, drugs in lower tiers cost less than drugs in higher tiers. Although carrier tiers can differ in cost and components, generally, the four available tiers are:

Tier 1 – Generic drugs. This tier offers the lowest copays for consumers. They are often classified as “preferred,” since they tend to be very effective at treatment, and are also the least expensive option. Tier 1 drugs are typically divided into two separate tiers (below).

Tier 1A – Preferred generic drugs. Popular generic substitutes for brand name drugs that often are used in the treatment of chronic diseases. This group has the lowest generic copay.

Tier 1B – All other generic drugs. This group has the largest generic copay.

Tier 2 – Preferred brand drugs that do not have a generic substitute. Copays are higher than Tier 1 drugs.

Tier 3 – Non-preferred brand drugs. This tier includes brand-name (non-preferred) drugs that have no generic substitute alternative. Often these drugs are not included in benefits or have expensive copays.

Tier 4 – Preferred Specialty. Brand-name and specialty drugs are found in this tier. Typically, serious and chronic health conditions are treated with the medications. They are also less costly than Tier 5 drugs.

Tier 5 – Nonpreferred Specialty. The most expensive option and often not covered by insurers. More cost-effective and inexpensive options are typically offered in other tiers.

Note: A “PA” designation signifies that prior authorization may be required to purchase the medication. A “QL” designation  means that their may be a limitation on the amount distributed.

 

Plan Rules

Hospital Outpatient – Drugs received from the ER and observation services may not be covered by Medicare Part B. Common examples are self-administered drugs. A claim may be needed to obtain a refund. of the money you paid.

Step Therapy – Prior authorization is often needed since an effective and less-expensive option may be available. A generic drug may be initially recommended, followed by a lower-cost brand-name drug. In some situations, the more expensive option may be the most effective treatment for a specific ailment. An exception can also be requested if an adverse reaction can occur with a generic drug.

Opioid Pain Medication – A safety review may be performed to verify the dosage is correct or other potentially-harmful drug interactions are avoided. A 7-day supply may be the maximum dosage initially allowed. A drug management program may be offered to provide additional safety measures since very serious health risks can result from misuse.

Part D Vaccines – Commercially-offered vaccines are required to be covered when determined to be “medically necessary.”

Quantity Limits – Often, the amount and timing of dosages are limited to protect the consumer. However, your physician can request that the plan make an exception.

Prior Authorization – Specific prescriptions may require you to  contact the plan for authorization to verify it is medically-necessary. Often, a medication is approved for specific conditions, but not other related conditions.

Note: If your policy drug plan card has not been issued yet, Alternative proof options may be utilized. A welcome or acknowledgement letter will be accepted along with a copy of your Medicare card. Also, the plan phone number, name, and conformation number will be accepted.

 

Ohio PDP Plan Details

24 plans are available, which is a decrease of seven from last year. 15 Enhanced alternative (EA) options are offered in the Buckeye State. EA plans have a value which exceeds the defined standard coverage. Supplemental benefits sometimes include a reduction in copays or coinsurance (initial coverage phase), reduction of the initial deductible, and a reduction of cost-sharing in the initial coverage gap. Nine additional plans (Basic alternative, Defined standard, and an actuarial equivalent) are also offered.

Four $0 Deductible plans can be purchased. They are AARP MedicareRx Preferred, WellCare Medicare Rx Value Plus, SilverScript Plus, and Anthem MediBlue Rx Plus. Six plans are available with premiums less than $25. Monthly premiums for all plans range from $5.10 (SilverScript SmartSaver) to $109.20 (AARP MedicareRx Preferred). The average cost of all policies is $47.07 per month, and four plans offer gap coverage in the donut hole.

Seven Part D plans in Ohio  had rate decreases, and 15 plans had rate increases. Approximately 68% of all policy owners had policy rate increases, and the average amount was $7.98. The LIS Benchmark premium is $34.71 per month, and five plans are LIS-qualified (WellCare Classic, SilverScipt Choice, Cigna Secure Rx, and Clear Sping Health Value Rx). The most popular Ohio Part D plans are Wellcare Value Script, SilverScript Smart Saver, SilverScript Choice, Elixir RxSecure, AARP Medicare Rx Preferred, Humana Walmart Value Rx Plan, and Wellcare Classic.

 

Ohio PDP Coverage

 

AARP MedicareRx Walgreens – $28.20 per month and $350 deductible. No additional gap coverage. 3,251 formulary drugs available. 30-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $1, $10, $40, 45%, and 27%. 90-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $3, $30, $120, 45%, and n/a. 25,082 enrolled members reside in Ohio. 770,583 enrolled members reside in the US. The Plan Summary Star Rating is 3.0. The Plan ID is S5921-395. The number of available drugs in each tier is 54 (Tier 1), 537 (Tier 2), 1,041 (Tier 3), 956 (Tier 4), and 663 (Tier 5). Insulin formulary monthly copay is less than $35 per month.

AARP MedicareRx Saver Plus – $50.00 per month and $505 deductible. No additional gap coverage. 3,170 formulary drugs available. 30-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $1, $19, 17%, 42%, and 25%. 90-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $3, $57, 17%, 42%, and n/a. 18,840 enrolled members reside in Ohio. 842,877 enrolled members reside in the US. The Plan Summary Star Rating is 3.0. The Plan ID is S5921-359. The number of available drugs in each tier is 54 (Tier 1), 798 (Tier 2), 732 (Tier 3), 954 (Tier 4), and 632 (Tier 5). Insulin formulary monthly copay is less than $35 per month.

AARP MedicareRx Preferred – $108.20 per month and $0 deductible. Some additional gap coverage available. 3,624 formulary drugs available. 30-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $7, $12, $47, 40%, and 33%. 90-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $21, $36, $141, 40%, and n/a. 61,358 enrolled members reside in Ohio. 1,544,826 enrolled members reside in the US. The Plan Summary Star Rating is 3.5. The Plan ID is S5820-013. The number of available drugs in each tier is 157 (Tier 1), 725 (Tier 2), 980 (Tier 3), 1,063 (Tier 4), and 699 (Tier 5). Insulin formulary monthly copay is less than $35 per month.

Anthem MediBlue Rx Standard – $58.30 per month and $360 deductible. No additional gap coverage. 2,921 formulary drugs available. 30-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $1, $5, $47, 35%, and 27%. 90-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $3, $15, $141, 35%, and n/a. 6,158 enrolled members reside in Ohio. 46,098 enrolled members reside in the US. The Plan Summary Star Rating is 4.0. The Plan ID is S5596-013. The number of available drugs in each tier is 63 (Tier 1), 463 (Tier 2), 1,106 (Tier 3), 816 (Tier 4), and 473 (Tier 5). Policy ID S5596-013.

Anthem MediBlue Rx Plus – $80.40 per month and $0 deductible. No additional gap coverage. 3,116 formulary drugs available. 30-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $1, $3, $47, 50%, and 33%. 90-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $3, $9, $141, 50%, and n/a. 11,822 enrolled members reside in Ohio. 70,822 enrolled members reside in the US. The Plan Summary Star Rating is 4.0. The Plan ID is S5596-014. The number of available drugs in each tier is 146 (Tier 1), 528 (Tier 2), 1,058 (Tier 3), 890 (Tier 4), and 494 (Tier 5). Select insulin copay is $35. Policy ID S5596-014.

Cigna Secure Rx – $32.50 per month and $480 deductible. No additional gap coverage. 3,143 formulary drugs available. 30-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $1, $10, $47, 50%, and 25%. 90-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $3, $30, $141, 50%, and n/a. 7,158 enrolled members reside in Ohio. 530,416 enrolled members reside in the US. The Plan Summary Star Rating is 3.5. The Plan ID is S5617-068. The number of available drugs in each tier is 83 (Tier 1), 557 (Tier 2), 655 (Tier 3), 1,287 (Tier 4), and 461 (Tier 5). Policy ID S5617-068.

Cigna Essential Rx – $44.50 per month and $480 deductible. No additional gap coverage. 3,134 formulary drugs available. 30-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $0, $2, 18%, 49%, and 25%. 90-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $0, $18, 18%, 50%, and n/a. 6,080 enrolled members reside in Ohio. 242,100 enrolled members reside in the US. The Plan Summary Star Rating is 3.5. The Plan ID is S5617-293. The number of available drugs in each tier is 149 (Tier 1), 596 (Tier 2), 523 (Tier 3), 1,407 (Tier 4), and 459 (Tier 5). Policy ID S5617-293.

Cigna Extra Rx – $53.00 per month and $100 deductible. Additional gap coverage available. 3,231 formulary drugs available. 30-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $4, $10, $42, 50%, and 31%. 90-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $12, $30, $126, 50%, and n/a. 6,140 enrolled members reside in Ohio. 159,937 enrolled members reside in the US. The Plan Summary Star Rating is 3.5. The Plan ID is S5617-259. The number of available drugs in each tier is 179 (Tier 1), 671 (Tier 2), 726 (Tier 3), 1,157 (Tier 4), and 472 (Tier 5). Select insulin copay is $11. Policy ID S5617-068.

Clear Spring Health Premier Rx – $17.00 per month and $480 deductible. No additional gap coverage. 3,150 formulary drugs available. 30-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $1, $5, $42, 45%, and 25%. 90-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $3, $15, $126, 45%, and 25%. 3,710 enrolled members reside in Ohio. 201,342 enrolled members reside in the US. The Plan ID is S6946-040. The number of available drugs in each tier is 212 (Tier 1), 235 (Tier 2), 848 (Tier 3), 1,282 (Tier 4), and 573 (Tier 5). Policy ID S6946-040.

Clear Spring Health Value Rx – $40.90 per month and $480 deductible. No additional gap coverage. 3,138 formulary drugs available. 30-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $1, $3, $42, 34%, and 25%. 90-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $3, $9, $126, 34%, and 25%. 4,063 enrolled members reside in Ohio. 90,432 enrolled members reside in the US. The Plan ID is S6946-011. The number of available drugs in each tier is 209 (Tier 1), 597 (Tier 2), 497 (Tier 3), 1,266 (Tier 4), and 569 (Tier 5). Policy ID S6946-011.

Elixir RxPlus – $20.30 per month and $480 deductible. No additional gap coverage. 3,133 formulary drugs available. 30-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $1, $6, $43, 45%, and 25%. 90-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $3, $18, $129, 45%, and n/a. Plan Summary Star Rating is 3.0. The Plan ID is S7694-132. The number of available drugs in each tier is 208 (Tier 1), 555 (Tier 2), 565 (Tier 3), 1,236 (Tier 4), and 569 (Tier 5). Policy ID S7694-132.

Elixir RxSecure – $32.80 per month and $480 deductible. No additional gap coverage. 3,062 formulary drugs available. 30-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $1, $4, 15%, 29%, and 25%. 90-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $3, $12, 15%, 29%, and n/a. 87,304 enrolled members reside in Ohio. 417,265 enrolled members reside in the US.  Plan Summary Star Rating is 3.0. The Plan ID is S7694-014. The number of available drugs in each tier is 208 (Tier 1), 544 (Tier 2), 546 (Tier 3), 1,205 (Tier 4), and 559 (Tier 5). Policy ID S6946-014.

Humana Walmart Value Rx Plan – $22.70 per month and $480 deductible. No additional gap coverage available. 3,184 formulary drugs available. 30-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $1, $4, $18, 42%, and 25%. 90-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $3, $12, 18%, 42%, and n/a. 42,257 enrolled members reside in Ohio. 1,130,196 enrolled members reside in the US.  Plan Summary Star Rating is 4.0. The Plan ID is S5884-193. The number of available drugs in each tier is 156 (Tier 1), 686 (Tier 2), 716 (Tier 3), 1,050 (Tier 4), and 576 (Tier 5). Policy ID S5884-193.

Humana Premier Rx Plan – $81.20 per month and $480 deductible. No additional gap coverage available. 3,242 formulary drugs available. 30-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $1, $4, $45, 49%, and 25%. 90-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $3, $12, $135, 49%, and n/a. 40,291 enrolled members reside in Ohio. 1,083,163 enrolled members reside in the US.  Plan Summary Star Rating is 4.0. The Plan ID is S5884-160. The number of available drugs in each tier is 259 (Tier 1), 587 (Tier 2), 738 (Tier 3), 1,081 (Tier 4), and 577 (Tier 5). Select insulin copay is $35.

Humana Basic Rx Plan – $42.30 per month and $480 deductible. No additional gap coverage available. 3,060 formulary drugs available. 30-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $0, $1, 21%, 49%, and 25%. 90-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $0, $3, 21%, 49%, and n/a. 15,677 enrolled members reside in Ohio. 1,286,538 enrolled members reside in the US.  Plan Summary Star Rating is 4.0. The Plan ID is S5884-137. The number of available drugs in each tier is 142 (Tier 1), 637 (Tier 2), 730 (Tier 3), 993 (Tier 4), and 598 (Tier 5).

Mutual Of Omaha Rx Plus – $81.60 per month and $480 deductible. No additional gap coverage available. 2,938 formulary drugs available. 30-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $1, $3, 19%, 42%, and 25%. 90-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $3, $9, 19%, n/a, and n/a. 836 enrolled members reside in Ohio. 19,079 enrolled members reside in the US.  Plan Summary Star Rating is 3.5. The Plan ID is S7126-013. The number of available drugs in each tier is 137 (Tier 1), 607 (Tier 2), 643 (Tier 3), 1,101 (Tier 4), and 459 (Tier 5).

Mutual Of Omaha Rx Premier – $34.40 per month and $480 deductible. No additional gap coverage available. 2,985 formulary drugs available. 30-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $0, $13, 23%, 44%, and 25%. 90-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $0, $39, 23%, n/a, and n/a. 4,345 enrolled members reside in Ohio. 98,661 enrolled members reside in the US.  Plan Summary Star Rating is 3.5. The Plan ID is S7126-083. The number of available drugs in each tier is 137 (Tier 1), 605 (Tier 2), 709 (Tier 3), 1,073 (Tier 4), and 470 (Tier 5). Select insulin copay is $35.

SilverScript Plus – $75.20 per month and $0 deductible. Additional additional gap coverage available. 3,252 formulary drugs available. 30-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $0, $2, $47, 50%, and 33%. 90-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $0, $0, $120, 50%, and n/a. 7,803 enrolled members reside in Ohio. 235,531 enrolled members reside in the US.  Plan Summary Star Rating is 3.5. The Plan ID is S5601-029. The number of available drugs in each tier is 195 (Tier 1), 644 (Tier 2), 808 (Tier 3), 1,046 (Tier 4), and 574 (Tier 5). Select insulin copay is $35.

SilverScript Choice – $30.30 per month and $480 deductible. No additional additional gap coverage available. 3,082 formulary drugs available. 30-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $0, $5, $18, 40%, and 25%. 90-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $0, $15, 18%, 40%, and n/a. 82,672 enrolled members reside in Ohio. 3,214,280 enrolled members reside in the US.  Plan Summary Star Rating is 3.5. The Plan ID is S5601-028. The number of available drugs in each tier is 97 (Tier 1), 599 (Tier 2), 829 (Tier 3), 1,013 (Tier 4), and 560 (Tier 5).

SilverScript SmartRx – $7.10 per month and $480 deductible. No additional additional gap coverage available. 3,578 formulary drugs available. 30-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $1, $19, $46, 49%, and 25%. 90-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $3, $57, $138, 49%, and n/a. 68,432 enrolled members reside in Ohio. 1,201,863 enrolled members reside in the US.  Plan Summary Star Rating is 3.5. The Plan ID is S5601-189. The number of available drugs in each tier is 250 (Tier 1), 621 (Tier 2), 787 (Tier 3), 1,364 (Tier 4), and 572 (Tier 5).

WellCare Medicare Rx Value Plus – $68.90 per month and $0 deductible. No additional additional gap coverage available. 3,464 formulary drugs available. 30-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $0, $4, $47, 50%, and 33%. 90-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $3, $12, $141, 50%, and n/a. 29,571 enrolled members reside in Ohio. 577,317 enrolled members reside in the US.  Plan Summary Star Rating is 3.5. The Plan ID is S5768-137. The number of available drugs in each tier is 363 (Tier 1), 433 (Tier 2), 1,046 (Tier 3), 950 (Tier 4), and 672 (tier 5). Select insulin copay is $35.

WellCare Classic – $28.80 per month and $480 deductible. No additional additional gap coverage available. 3,450 formulary drugs available. 30-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $0, $7, $40, 35%, and 25%. 90-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $0, $21, $120, 35%, and n/a. 48,834 enrolled members reside in Ohio. 1,473,307 enrolled members reside in the US.  Plan Summary Star Rating is 3.5. The Plan ID is S4802-085. The number of available drugs in each tier is 123 (Tier 1), 461 (Tier 2), 1,093 (Tier 3), 863 (Tier 4), and 570 (tier 5).

WellCare Value Script – $12.90 per month and $480 deductible. No additional additional gap coverage available. 3,463 formulary drugs available. 30-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $0, $4, $42, 47%, and 25%. 90-day preferred generic, generic, preferred brand, non-preferred, and specialty drug copays are $0, $12, $126, 47%, and n/a. 103,271 enrolled members reside in Ohio. 2,110,703 enrolled members reside in the US.  Plan Summary Star Rating is 3.5. The Plan ID is S4802-183. The number of available drugs in each tier is 347 (Tier 1), 444 (Tier 2), 1,031 (Tier 3), 955 (Tier 4), and 673 (tier 5). Select insulin copay is $35.