VANCOMYCIN HCL 125 MG CAPSULE (NDC: 17478074102)
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 SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 | Some Generics | 5 |
Specialty Tier |
33% | 33% | P | $3,077.03 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 | Some Generics | 5 |
Specialty Tier |
33% | 33% | P | $3,077.03 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 | Some Generics | 5 |
Specialty Tier |
33% | 33% | P | $3,077.03 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Premier (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | 33% | P | $3,077.03 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 | Some Generics | 2 |
Non-Preferred Generic |
$33.00 | $66.00 | None | $2,807.98 |
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 Select Plan (HMO)
|
$0.00 |
$0 | Some Generics | 2 |
Non-Preferred Generic |
$33.00 | $66.00 | None | $2,807.98 |
Browse Plan Formulary |
Blue Cross Senior Secure Plan I (HMO)
|
$0.00 |
$0 | Many Generics | 6 |
Specialty Tier |
33% | n/a | P Q:40 /1Days | $3,014.47 |
Browse Plan Formulary |
Blue Cross Senior Secure Plan I (HMO)
|
$0.00 |
$0 | Many Generics | 6 |
Specialty Tier |
33% | n/a | P Q:40 /1Days | $3,014.47 |
Browse Plan Formulary |
Blue Cross Senior Secure Plan II (HMO)
|
$0.00 |
$0 | Many Generics | 6 |
Specialty Tier |
33% | n/a | P Q:40 /1Days | $3,014.47 |
Browse Plan Formulary |
Blue Cross Senior Secure Plan II (HMO)
|
$0.00 |
$0 | Many Generics | 6 |
Specialty Tier |
33% | n/a | P Q:40 /1Days | $3,014.47 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 | Many Generics | 5 |
Specialty Tier |
33% | 33% | None | $2,346.21 |
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 |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 | Many Generics | 5 |
Specialty Tier |
33% | 33% | None | $2,346.21 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 | Many Generics | 5 |
Specialty Tier |
33% | 33% | None | $2,346.21 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 | Many Generics | 5 |
Specialty Tier |
33% | 33% | None | $2,346.21 |
Browse Plan Formulary |
Brand New Day (HMO)
|
$0.00 |
$0 | Many Generics | 2 |
Brand |
$40.00 | $80.00 | None | $2,303.59 |
Browse Plan Formulary |
Brand New Day (HMO)
|
$0.00 |
$0 | Many Generics | 2 |
Brand |
$40.00 | $80.00 | None | $2,303.59 |
Browse Plan Formulary |
Care1st AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 | Many Generics | 5 |
Specialty Tier |
30% | 30% | None | $2,283.92 |
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 |
Care1st AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 | Many Generics | 5 |
Specialty Tier |
30% | 30% | None | $2,283.92 |
Browse Plan Formulary |
Care1st TotalAdvantage Plan (HMO)
|
$0.00 |
$0 | Many Generics | 5 |
Specialty Tier |
30% | 30% | None | $2,283.92 |
Browse Plan Formulary |
Citizens Choice Healthplan (HMO)
|
$0.00 |
$0 | Many Generics | 1 |
Generic |
$0.00 | $0.00 | None | $2,220.03 |
Browse Plan Formulary |
Citizens Choice Healthplan (HMO)
|
$0.00 |
$0 | Many Generics | 1 |
Generic |
$0.00 | $0.00 | None | $2,220.03 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 | Many Generics | 5 |
Specialty Tier |
25% | 25% | None | $2,303.59 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 | Many Generics | 5 |
Specialty Tier |
25% | 25% | None | $2,303.59 |
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 |
Freedom VIP Care (HMO SNP)
|
$0.00 |
$0 | Many Generics | 5 |
Specialty Tier |
25% | 25% | None | $2,303.59 |
Browse Plan Formulary |
Freedom VIP Care (HMO SNP)
|
$0.00 |
$0 | Many Generics | 5 |
Specialty Tier |
25% | 25% | None | $2,303.59 |
Browse Plan Formulary |
Freedom VIP Care COPD (HMO SNP)
|
$0.00 |
$0 | Many Generics | 5 |
Specialty Tier |
25% | 25% | None | $2,303.59 |
Browse Plan Formulary |
Freedom VIP Care COPD (HMO SNP)
|
$0.00 |
$0 | Many Generics | 5 |
Specialty Tier |
25% | 25% | None | $2,303.59 |
Browse Plan Formulary |
Golden State Medicare Health Plan, Golden (HMO) (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Specialty Tier |
33% | 33% | P | $3,090.78 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 | Many Generics | 5 |
Specialty Tier |
33% | 33% | P | $2,816.13 |
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 |
Health Net Gold Select (HMO)
|
$0.00 |
$0 | Many Generics | 5 |
Specialty Tier |
33% | 33% | P | $2,816.13 |
Browse Plan Formulary |
Health Net Healthy Heart Plan 1 (HMO)
|
$0.00 |
$0 | Many Generics | 5 |
Specialty Tier |
33% | 33% | P | $2,816.13 |
Browse Plan Formulary |
Health Net Healthy Heart Plan 1 (HMO)
|
$0.00 |
$0 | Many Generics | 5 |
Specialty Tier |
33% | 33% | P | $2,816.13 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 | Many Generics | 5 |
Specialty Tier |
33% | 33% | P | $2,816.13 |
Browse Plan Formulary |
Health Net Jade (HMO SNP)
|
$0.00 |
$0 | Many Generics | 5 |
Specialty Tier |
33% | 33% | P | $2,816.13 |
Browse Plan Formulary |
Health Net Seniority Plus Ruby Plan 1 (HMO)
|
$0.00 |
$0 | Many Generics | 5 |
Specialty Tier |
33% | 33% | P | $2,816.13 |
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 |
Health Net Seniority Plus Ruby Plan 1 (HMO)
|
$0.00 |
$0 | Many Generics | 5 |
Specialty Tier |
33% | 33% | P | $2,816.13 |
Browse Plan Formulary |
Heart First (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 5 |
Specialty Tier |
33% | n/a | P | $2,883.82 |
Browse Plan Formulary |
Heart First (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 5 |
Specialty Tier |
33% | n/a | P | $2,883.82 |
Browse Plan Formulary |
Humana Gold Plus H0108-013 (HMO)
|
$0.00 |
$0 | Some Generics, Few Brands | 5 |
Specialty Tier |
33% | n/a | None | $1,942.45 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
$8.00 | $16.00 | None | $2,991.32 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
$8.00 | $16.00 | None | $2,991.32 |
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 |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 | All Generics, Few Brands | 2 |
Non-Preferred Generic |
$7.00 | $14.00 | None | $2,991.32 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 | All Generics, Few Brands | 2 |
Non-Preferred Generic |
$7.00 | $14.00 | None | $2,991.32 |
Browse Plan Formulary |
Positive Healthcare Partners (HMO SNP)
|
$0.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
25% | n/a | P | $2,292.27 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 5 |
Specialty Tier |
33% | n/a | P | $2,883.82 |
Browse Plan Formulary |
SCAN Balance (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 5 |
Specialty Tier |
33% | n/a | P | $2,883.82 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 | Many Generics | 5 |
Specialty Tier |
33% | n/a | P | $2,883.82 |
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 |
SCAN Classic (HMO)
|
$0.00 |
$0 | Many Generics | 5 |
Specialty Tier |
33% | n/a | P | $2,883.82 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 | Many Generics | 5 |
Specialty Tier |
33% | n/a | P | $2,883.82 |
Browse Plan Formulary |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 | Many Generics | 5 |
Specialty Tier |
33% | n/a | P | $2,883.82 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$11.40 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $2,991.32 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$11.40 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $2,991.32 |
Browse Plan Formulary |
Health Net Healthy Heart Plan 2 (HMO)
|
$23.90 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | 33% | P | $2,816.13 |
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 Dual Complete (HMO SNP)
|
$26.90 |
$325 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
15% | 15% | P | $3,077.03 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H0108-016 (HMO SNP)
|
$27.40 |
$325 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
15% | 15% | None | $1,942.45 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$27.50 |
$325 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | n/a | P | $2,883.82 |
Browse Plan Formulary |
Anthem Medicare Preferred Standard (PPO)
|
$28.00 |
$90* | No additional gap coverage, only the Donut Hole Discount | 6* |
Specialty Tier |
33% | n/a | P Q:40 /1Days | $3,014.47 |
Browse Plan Formulary |
Brand New Day (HMO SNP)
|
$29.80 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $2,303.59 |
Browse Plan Formulary |
Brand New Day (HMO SNP)
|
$29.80 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $2,303.59 |
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 |
Brand New Day D SNP (HMO SNP)
|
$29.80 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $2,303.59 |
Browse Plan Formulary |
Brand New Day D SNP (HMO SNP)
|
$29.80 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $2,303.59 |
Browse Plan Formulary |
Brand New Day HMO Extra Care (HMO)
|
$29.80 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $2,303.59 |
Browse Plan Formulary |
Brand New Day HMO Extra Care (HMO)
|
$29.80 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $2,303.59 |
Browse Plan Formulary |
Care1st TotalDual Plan (HMO SNP)
|
$29.80 |
$325 | Few Generics | 5 |
Specialty Tier |
25% | 25% | None | $2,283.92 |
Browse Plan Formulary |
Care1st TotalDual Plan (HMO SNP)
|
$29.80 |
$325 | Few Generics | 5 |
Specialty Tier |
25% | 25% | None | $2,283.92 |
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 |
Health Net Seniority Plus Amber I (HMO SNP)
|
$29.80 |
$325 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
15% | 15% | P | $2,816.13 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$29.80 |
$325 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
15% | 15% | P | $2,816.13 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$29.80 |
$325 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
15% | 15% | P | $2,816.13 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$29.80 |
$325 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
15% | 15% | P | $2,816.13 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$29.80 |
$325 | No additional gap coverage, only the Donut Hole Discount | 4 |
Specialty Tier |
25% | n/a | None | $2,890.18 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$29.90 |
$325 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | 25% | None | $2,303.59 |
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 |
Freedom Plan (HMO SNP)
|
$29.90 |
$325 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
25% | 25% | None | $2,303.59 |
Browse Plan Formulary |
L.A. Care Health Plan Medicare Advantage (HMO SNP)
|
$29.90 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
n/a | n/a | None | $2,302.28 |
Browse Plan Formulary |
OneCare (HMO SNP)
|
$29.90 |
$0 | Few Generics | 2 |
Preferred Brand |
$0.00 | n/a | P | $1,919.81 |
Browse Plan Formulary |
SCAN Connections (HMO SNP)
|
$29.90 |
$325 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
n/a | n/a | P | $2,883.82 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
|
$29.90 |
$325 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
n/a | n/a | P | $2,883.82 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$29.90 |
$325 | No additional gap coverage, only the Donut Hole Discount | 5 |
Tier 5 |
15% | 15% | P | $3,077.03 |
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 |
Health Net Healthy Heart Plan 2 (HMO)
|
$39.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 5 |
Specialty Tier |
33% | 33% | P | $2,816.13 |
Browse Plan Formulary |
Humana Gold Plus H0108-014 (HMO-POS)
|
$39.00 |
$0 | Few Generics, Few Brands | 5 |
Specialty Tier |
33% | n/a | None | $1,942.45 |
Browse Plan Formulary |
Anthem Medicare Preferred Standard (PPO)
|
$66.00 |
$90* | No additional gap coverage, only the Donut Hole Discount | 6* |
Specialty Tier |
33% | n/a | P Q:40 /1Days | $3,014.47 |
Browse Plan Formulary |