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 |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $45.02 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $45.02 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $45.02 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $45.02 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $45.02 |
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 |
Paramount Elite - Standard Medical and Drug (HMO)
|
$0.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
4* |
Injectable Drugs |
33% | n/a | None | $47.74 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$12.50 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $45.02 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$12.50 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $45.02 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$12.50 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $45.02 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$12.50 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $45.02 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$12.50 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $45.02 |
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 |
HumanaChoice R5826-072 (Regional PPO)
|
$20.80 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | None | $60.12 |
Browse Plan Formulary |
CareSource Advantage (HMO SNP)
|
$34.20 |
$325* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Generic |
$0.00 | $0.00 | None | $47.35 |
Browse Plan Formulary |
HumanaChoice R5826-006 (Regional PPO)
|
$37.50 |
$0 |
Few Generics, Few Brands |
3 |
Non-Preferred Brand |
$80.00 | $230.00 | None | $60.12 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$43.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$9.00 | $22.50 | None | $40.75 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$44.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None | $41.66 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$47.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$10.00 | $25.00 | None | $40.75 |
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 |
PriorityMedicare Merit (PPO)
|
$47.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$10.00 | $25.00 | None | $40.75 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$47.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$10.00 | $25.00 | None | $40.75 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$56.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $45.02 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$56.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $45.02 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$56.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $45.02 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$56.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $45.02 |
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 Plus Blue PPO Vitality (PPO)
|
$56.00 |
$325 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $45.02 |
Browse Plan Formulary |
HumanaChoice H5470-002 (PPO)
|
$62.00 |
$0 |
Few Generics, Few Brands |
3 |
Non-Preferred Brand |
$83.00 | $239.00 | None | $60.12 |
Browse Plan Formulary |
Humana Gold Choice H8145-005 (PFFS)
|
$72.00 |
$0 |
Few Generics, Few Brands |
3 |
Non-Preferred Brand |
$80.00 | $230.00 | None | $60.12 |
Browse Plan Formulary |
Paramount Elite - Enhanced Medical and Drug (HMO)
|
$86.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Injectable Drugs |
33% | n/a | None | $47.74 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$88.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $45.02 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$88.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $45.02 |
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 |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$88.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $45.02 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$88.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $45.02 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$88.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $45.02 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$94.00 |
$25 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None | $41.66 |
Browse Plan Formulary |
Alliance Medicare PPO (PPO)
|
$103.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None | $41.65 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$107.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$8.00 | $20.00 | None | $40.75 |
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 |
PriorityMedicare Select (PPO)
|
$111.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
$8.00 | $20.00 | None | $40.75 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$128.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None | $45.02 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$128.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None | $45.02 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$128.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None | $45.02 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$128.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None | $45.02 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$128.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $37.50 | None | $45.02 |
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 |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$169.00 |
$25 |
All Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $41.66 |
Browse Plan Formulary |
Alliance Medicare PPO (PPO)
|
$174.00 |
$50 |
All Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $41.65 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$194.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $45.10 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$194.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $45.10 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$194.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $45.10 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$194.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $45.10 |
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 Plus Blue PPO Assure (PPO)
|
$194.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $45.10 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$218.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $45.02 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$218.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $45.02 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$218.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $45.02 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$218.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $45.02 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$218.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $45.02 |
Browse Plan Formulary |