AMPICILLIN FOR ORAL SUSPENSION 250MG 100ML BOT (100 ML BOT) (NDC: 67253018310)
2013 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
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 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $116.00 | None | $7.81 |
Browse Plan Formulary |
AARP MedicareComplete Plus (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $7.81 |
Browse Plan Formulary |
Advantra Elite (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$18.00 | $36.00 | None | $7.58 |
Browse Plan Formulary |
Advantra Preferred (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$18.00 | $36.00 | None | $7.55 |
Browse Plan Formulary |
Advantra Silver (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$18.00 | $36.00 | None | $7.58 |
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 Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$7.00 | $14.00 | None | $6.90 |
Browse Plan Formulary |
BlueValue Basic (HMO)
|
$0.00 |
$60* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None | $13.56 |
Browse Plan Formulary |
Care Improvement Plus Copper RX (PPO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$6.00 | $15.00 | None | $6.49 |
Browse Plan Formulary |
Care Improvement Plus Copper RX (Regional PPO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$8.00 | $20.00 | None | $6.49 |
Browse Plan Formulary |
Care Improvement Plus Gold Rx (PPO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$6.00 | $15.00 | None | $6.49 |
Browse Plan Formulary |
Care Improvement Plus Gold Rx (Regional PPO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$8.00 | $20.00 | None | $6.49 |
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 |
Care Improvement Plus Medicare Advantage (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$6.00 | $15.00 | None | $6.49 |
Browse Plan Formulary |
Care Improvement Plus Medicare Advantage (Regional PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$8.00 | $20.00 | None | $6.49 |
Browse Plan Formulary |
Humana Gold Plus H4141-001 (HMO)
|
$0.00 |
$0 |
Some Generics, Few Brands |
2 |
Non-Preferred Generic |
$6.00 | $0.00 | None | $17.04 |
Browse Plan Formulary |
Humana Gold Plus SNP-CVD/CHF/DM H4141-009 (HMO SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
2 |
Non-Preferred Generic |
$6.00 | $0.00 | None | $17.04 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage Basic (HMO)
|
$0.00 |
$0 |
All Generics, Few Brands |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $15.93 |
Browse Plan Formulary |
WellCare Value (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$3.00 | $0.00 | None | $13.80 |
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 |
WellCare Access (HMO SNP)
|
$17.90 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$45.00 | $90.00 | None | $13.80 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H4141-003 (HMO SNP)
|
$24.80 |
$325* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$0.00 | $0.00 | None | $17.04 |
Browse Plan Formulary |
Medicare Preferred Core (PPO)
|
$25.00 |
$91 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $15.00 | None | $13.56 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (PPO SNP)
|
$26.30 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $7.69 |
Browse Plan Formulary |
HumanaChoice R5826-077 (Regional PPO)
|
$29.60 |
$150* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$12.00 | $0.00 | None | $17.06 |
Browse Plan Formulary |
Senior Advantage Medicare Medicaid Plan (HMO SNP)
|
$30.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None | $15.93 |
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 |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$30.90 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | None | $8.52 |
Browse Plan Formulary |
Advantage by Peach State Health Plan (HMO SNP)
|
$31.00 |
$325* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Generic |
$0.00 | $0.00 | None | $12.40 |
Browse Plan Formulary |
Fresenius Health Partners (PPO SNP)
|
$33.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $6.97 |
Browse Plan Formulary |
Care Improvement Plus Chrome RX (PPO SNP)
|
$34.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $6.49 |
Browse Plan Formulary |
Care Improvement Plus Dual Advantage (PPO SNP)
|
$34.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
n/a | n/a | None | $6.49 |
Browse Plan Formulary |
Care Improvement Plus Silver Rx (PPO SNP)
|
$34.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $6.49 |
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 |
Care Improvement Plus Silver Rx (Regional PPO SNP)
|
$36.30 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $6.49 |
Browse Plan Formulary |
Care Improvement Plus Chrome RX (Regional PPO SNP)
|
$36.50 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $6.49 |
Browse Plan Formulary |
Care Improvement Plus Dual Advantage (Regional PPO SNP)
|
$36.50 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
n/a | n/a | None | $6.49 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$45.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$7.00 | $14.00 | None | $6.90 |
Browse Plan Formulary |
HumanaChoice H5214-003 (PPO)
|
$47.00 |
$0 |
Few Generics, Few Brands |
2 |
Non-Preferred Generic |
$12.00 | $0.00 | None | $17.00 |
Browse Plan Formulary |
BlueValue Secure (HMO)
|
$48.00 |
$60* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$10.00 | $15.00 | None | $13.56 |
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 |
Medicare Preferred Premier (PPO)
|
$60.00 |
$91 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $15.00 | None | $13.56 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage Enhanced (HMO)
|
$61.00 |
$0 |
All Generics, Few Brands |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $15.93 |
Browse Plan Formulary |
Today''s Options Advantage Plus 650B (PPO)
|
$64.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$5.00 | $10.00 | None | $6.68 |
Browse Plan Formulary |
Advantra Silver Plus (HMO-POS)
|
$69.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$18.00 | $36.00 | None | $7.58 |
Browse Plan Formulary |
Humana Gold Choice H8145-079 (PFFS)
|
$72.00 |
$0 |
Few Generics, Few Brands |
2 |
Non-Preferred Generic |
$12.00 | $0.00 | None | $17.02 |
Browse Plan Formulary |
Today''s Options Premier Plus 650D (PFFS)
|
$92.00 |
$85 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$5.00 | $10.00 | None | $6.68 |
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 |
Today''s Options Advantage Plus 350A (PPO)
|
$127.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$2.00 | $4.00 | None | $6.68 |
Browse Plan Formulary |
Today''s Options Premier Plus 350A (PFFS)
|
$152.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$2.00 | $4.00 | None | $6.68 |
Browse Plan Formulary |