Ampicillin 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS (10 VIAL, GLASS in 1 PACKA ) (NDC: 00781340095)
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 Mosaic (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$44.00 | $122.00 | None | $43.99 |
Browse Plan Formulary |
AARP MedicareComplete Plan 1 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$44.00 | $122.00 | None | $43.99 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $43.99 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$33.00 | $66.00 | None | $47.51 |
Browse Plan Formulary |
Amerivantage Balance + Rx (HMO)
|
$0.00 |
$0 |
Some Generics |
2 |
Non-Preferred Generic |
$4.00 | $8.00 | None | $46.64 |
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 |
Amerivantage Classic Choice + Rx Plan (HMO-POS)
|
$0.00 |
$0 |
Some Generics |
2 |
Non-Preferred Generic |
$3.00 | $6.00 | None | $46.64 |
Browse Plan Formulary |
Easy Choice Diamond Rewards (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | P | $41.12 |
Browse Plan Formulary |
Easy Choice Diamond Rewards COPD (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | P | $41.12 |
Browse Plan Formulary |
Easy Choice Rewards (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | P | $41.12 |
Browse Plan Formulary |
Easy Choice Value (HMO)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | P | $41.12 |
Browse Plan Formulary |
Elderplan Classic: Zero Premium (HMO)
|
$0.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$4.00 | $10.00 | P | $43.80 |
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 |
Empire MediBlue COPD (HMO SNP)
|
$0.00 |
$0 |
Many Generics, Few Brands |
2 |
Non-Preferred Generic |
$5.00 | $12.50 | P | $47.03 |
Browse Plan Formulary |
Empire MediBlue Diabetes (HMO SNP)
|
$0.00 |
$0 |
Many Generics, Few Brands |
2 |
Non-Preferred Generic |
$5.00 | $12.50 | P | $47.03 |
Browse Plan Formulary |
Empire MediBlue Local (HMO)
|
$0.00 |
$0 |
Many Generics, Few Brands |
2 |
Non-Preferred Generic |
$5.00 | $12.50 | P | $47.03 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Injectable Drugs |
$95.00 | $237.50 | None | $47.03 |
Browse Plan Formulary |
Fidelis Medicare $0 Premium (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None | $47.85 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$0.00 | $0.00 | None | $45.64 |
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 |
Healthfirst Jade Benefits Plan (HMO)
|
$0.00 |
$0 |
Many Generics, Few Brands |
1 |
Generic |
$0.00 | $0.00 | None | $45.64 |
Browse Plan Formulary |
Liberty Health Advantage Preferred Choice (HMO)
|
$0.00 |
$0 |
All Generics |
4 |
Non-Preferred Brand |
$50.00 | $150.00 | P | $19.00 |
Browse Plan Formulary |
PPO II (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$5.00 | $10.00 | P | $47.32 |
Browse Plan Formulary |
Touchstone Health Medicare Freedom (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$80.00 | $200.00 | P | $19.00 |
Browse Plan Formulary |
Touchstone Health Medicare Power (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$80.00 | $200.00 | P | $19.00 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (Regional PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $43.99 |
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 |
VIP (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$5.00 | $10.00 | P | $47.32 |
Browse Plan Formulary |
VIP (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$5.00 | $10.00 | P | $47.32 |
Browse Plan Formulary |
VIP (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$5.00 | $10.00 | P | $47.32 |
Browse Plan Formulary |
VIP Essential (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$5.00 | $10.00 | P | $47.32 |
Browse Plan Formulary |
VIP Essential (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$5.00 | $10.00 | P | $47.32 |
Browse Plan Formulary |
VIP Essential (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$5.00 | $10.00 | P | $47.32 |
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 |
VNSNY CHOICE Medicare Enhanced (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$4.00 | $10.00 | None | $45.23 |
Browse Plan Formulary |
WellCare Choice (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$0.00 | $0.00 | None | $45.46 |
Browse Plan Formulary |
WellCare Rx (HMO)
|
$1.60 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$8.00 | $0.00 | None | $45.46 |
Browse Plan Formulary |
WellCare Liberty (HMO SNP)
|
$20.60 |
$325* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Generic |
$0.00 | $0.00 | None | $45.46 |
Browse Plan Formulary |
WellCare Advocate Complete (HMO SNP)
|
$28.40 |
$325* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Generic |
$0.00 | $0.00 | None | $45.46 |
Browse Plan Formulary |
MetroPlus Platinum (HMO)
|
$34.70 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $45.64 |
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 |
Healthfirst Increased Benefits Plan (HMO)
|
$35.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $45.64 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$35.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | None | $43.99 |
Browse Plan Formulary |
Empire MediBlue Freedom I (PPO)
|
$38.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
5* |
Injectable Drugs |
$95.00 | $237.50 | None | $47.03 |
Browse Plan Formulary |
Touchstone Health Medicare Total (HMO)
|
$38.60 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$80.00 | $200.00 | P | $19.00 |
Browse Plan Formulary |
HHH Choices Gold (HMO SNP)
|
$39.70 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $43.89 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Preferred (HMO SNP)
|
$40.10 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $45.23 |
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 |
Elderplan Advantage For Nursing Home Residents (HMO SNP)
|
$40.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | P | $43.80 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$40.40 |
$325* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Generic |
$0.00 | $0.00 | None | $45.46 |
Browse Plan Formulary |
Touchstone Health Medicare Prestige (HMO SNP)
|
$40.70 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
n/a | n/a | P | $19.00 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$41.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
n/a | n/a | None | $43.99 |
Browse Plan Formulary |
GuildNet Health Advantage (HMO-POS SNP)
|
$41.60 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P | $47.32 |
Browse Plan Formulary |
MetroPlus Advantage Plan (HMO SNP)
|
$41.70 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $45.64 |
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 LP (HMO SNP)
|
$42.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $43.99 |
Browse Plan Formulary |
Healthfirst AssuredCare (HMO SNP)
|
$43.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $45.64 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO SNP)
|
$43.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
n/a | n/a | None | $45.64 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO SNP)
|
$43.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $45.64 |
Browse Plan Formulary |
Healthfirst Maximum Plan (HMO SNP)
|
$43.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
n/a | n/a | None | $45.64 |
Browse Plan Formulary |
MetroPlus Select Plan (HMO SNP)
|
$43.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
n/a | n/a | None | $45.64 |
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 |
Affinity Medicare Solutions (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $46.64 |
Browse Plan Formulary |
Affinity Medicare Ultimate (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
0% | 0% | None | $46.64 |
Browse Plan Formulary |
Amerivantage Specialty + Rx (HMO SNP)
|
$43.20 |
$325* |
Many Generics, Few Brands |
2* |
Non-Preferred Generic |
$0.00 | $0.00 | None | $46.64 |
Browse Plan Formulary |
ArchCare - Inst and IE SNP - All Counties (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $47.35 |
Browse Plan Formulary |
CenterLight Direct Complete Plan (HMO SNP)
|
$43.20 |
$325* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Generic |
$7.25 | $21.75 | None | $47.47 |
Browse Plan Formulary |
CenterLight Direct Total Plan (HMO SNP)
|
$43.20 |
$185* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Generic |
$8.00 | $24.00 | None | $47.47 |
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 |
Dual Eligible (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$4.00 | $8.00 | P | $47.32 |
Browse Plan Formulary |
Dual Eligible (PPO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$4.00 | $8.00 | P | $47.32 |
Browse Plan Formulary |
Elderplan Extra Help (HMO)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | P | $43.80 |
Browse Plan Formulary |
Elderplan For Medicaid Beneficiaries (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P | $43.80 |
Browse Plan Formulary |
Elderplan Medicaid Advantage (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P | $43.80 |
Browse Plan Formulary |
Elderplan Plus Long Term Care (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | P | $43.80 |
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 |
Fidelis Dual Advantage (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None | $47.85 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO SNP)
|
$43.20 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None | $47.85 |
Browse Plan Formulary |
Fidelis Long Term Care Advantage (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $47.85 |
Browse Plan Formulary |
Fidelis Medicaid Advantage Plus (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None | $47.85 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
|
$43.20 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None | $47.85 |
Browse Plan Formulary |
GuildNet Gold (HMO-POS SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
n/a | n/a | P | $47.32 |
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 |
Liberty Health Advantage Dual Power (HMO SNP)
|
$43.20 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | P | $19.00 |
Browse Plan Formulary |
Senior Whole Health of New York (HMO SNP)
|
$43.20 |
$325* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Generic |
$0.00 | $0.00 | None | $48.39 |
Browse Plan Formulary |
PPO III (PPO)
|
$54.50 |
$0 |
All Generics |
1 |
Preferred Generic |
$5.00 | $10.00 | P | $47.32 |
Browse Plan Formulary |
MetroPlus Medicare Partnership in Care Plan (HMO SNP)
|
$67.10 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $45.64 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Maximum (HMO SNP)
|
$78.50 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
n/a | n/a | None | $45.23 |
Browse Plan Formulary |
VNSNY CHOICE Total (HMO SNP)
|
$95.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
n/a | n/a | None | $45.23 |
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 |
Empire MediBlue Freedom III (PPO)
|
$115.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
5 |
Injectable Drugs |
$95.00 | $237.50 | None | $47.03 |
Browse Plan Formulary |
PPO High Option (PPO)
|
$132.50 |
$0 |
All Generics |
1 |
Preferred Generic |
$5.00 | $10.00 | P | $47.32 |
Browse Plan Formulary |
VIP High Option (HMO)
|
$157.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$5.00 | $10.00 | P | $47.32 |
Browse Plan Formulary |
VIP High Option (HMO)
|
$157.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$5.00 | $10.00 | P | $47.32 |
Browse Plan Formulary |
VIP High Option (HMO)
|
$157.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$5.00 | $10.00 | P | $47.32 |
Browse Plan Formulary |