AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET (30 BOT) (NDC: 00781187431)
2015 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 |
Advantra Northern Pennsylvania Gold (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$9.00 | $27.00 | None | $122.24 |
Browse Plan Formulary |
Advantra Silver (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$12.00 | $30.00 | None | $123.75 |
Browse Plan Formulary |
Advantra Silver (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$13.00 | $39.00 | None | $123.58 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$20.00 | $60.00 | None | $132.24 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$20.00 | $60.00 | None | $119.58 |
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 |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$20.00 | $60.00 | None | $132.25 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$20.00 | $60.00 | None | $132.25 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$20.00 | $60.00 | None | $126.88 |
Browse Plan Formulary |
SeniorBlue - Option 3 (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$12.00 | $36.00 | None | $134.79 |
Browse Plan Formulary |
AdvantraOne (PPO)
|
$29.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$19.00 | $57.00 | None | $123.80 |
Browse Plan Formulary |
Advantra Cares (HMO SNP)
|
$33.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $109.39 |
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 |
Gateway Health Medicare Assured Diamond (HMO SNP)
|
$33.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | n/a | None | $121.82 |
Browse Plan Formulary |
Gateway Health Medicare Assured Ruby (HMO SNP)
|
$33.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | None | $121.82 |
Browse Plan Formulary |
Geisinger Gold Secure Rx (HMO SNP)
|
$33.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $130.27 |
Browse Plan Formulary |
HumanaChoice R5826-002 (Regional PPO)
|
$39.90 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$18.00 | $0.00 | None | $177.48 |
Browse Plan Formulary |
HumanaChoice H5525-007 (PPO)
|
$45.00 |
$320* |
Yes, but No Gap Coverage for this drug. |
2* |
Non-Preferred Generic |
$18.00 | $0.00 | None | $175.42 |
Browse Plan Formulary |
Gateway Health Medicare Assured Gold (HMO SNP)
|
$46.30 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $121.82 |
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 |
Advantra Silver Plus (HMO)
|
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$22.00 | $66.00 | None | $124.52 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (HMO)
|
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None | $133.36 |
Browse Plan Formulary |
Advantra Silver Plus (PPO)
|
$67.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$9.00 | $27.00 | None | $123.04 |
Browse Plan Formulary |
Freedom Blue PPO HD Rx (PPO)
|
$70.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$12.00 | $30.00 | None | $147.43 |
Browse Plan Formulary |
SeniorBlue - Option 2 (PPO)
|
$72.40 |
$0 |
to be determined |
2 |
Tier 2 |
$17.00 | $51.00 | None | $134.79 |
Browse Plan Formulary |
Gateway Health Medicare Assured Platinum (HMO SNP)
|
$77.80 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $121.82 |
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 |
Freedom Blue PPO ValueRx (PPO)
|
$95.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$12.00 | $30.00 | None | $147.43 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$116.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$8.00 | $20.00 | None | $123.58 |
Browse Plan Formulary |
SeniorBlue - Option 2 (HMO)
|
$117.50 |
$0 |
to be determined |
2 |
Tier 2 |
$12.00 | $36.00 | None | $134.79 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$124.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $45.00 | None | $133.49 |
Browse Plan Formulary |
Aetna Medicare Select Plus Plan (PPO)
|
$139.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$3.00 | $7.50 | None | $133.00 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$149.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $126.88 |
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 |
Geisinger Gold Classic Advantage Rx (HMO)
|
$149.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $132.24 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$149.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $119.58 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$149.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $132.25 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$149.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $132.25 |
Browse Plan Formulary |
SeniorBlue - Option 1 (HMO)
|
$167.50 |
$0 |
to be determined |
2 |
Tier 2 |
$9.00 | $27.00 | None | $134.79 |
Browse Plan Formulary |
Geisinger Gold Preferred Select Rx (PPO)
|
$179.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $132.15 |
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 |
Geisinger Gold Preferred Select Rx (PPO)
|
$179.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $119.58 |
Browse Plan Formulary |
Geisinger Gold Preferred Select Rx (PPO)
|
$179.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $132.25 |
Browse Plan Formulary |
SeniorBlue - Option 1 (PPO)
|
$191.90 |
$0 |
to be determined |
2 |
Tier 2 |
$10.00 | $30.00 | None | $134.79 |
Browse Plan Formulary |
Humana Gold Choice H8145-053 (PFFS)
|
$195.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$18.00 | $0.00 | None | $178.97 |
Browse Plan Formulary |
Freedom Blue PPO Standard (PPO)
|
$246.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$12.00 | $30.00 | None | $147.43 |
Browse Plan Formulary |
Freedom Blue PPO Deluxe (PPO)
|
$296.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$12.00 | $30.00 | None | $147.43 |
Browse Plan Formulary |