AMOXICILLIN 125MG TABLET CHEW (100 TABLETS BOT) (NDC: 00093226701)
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 |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $4.25 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $4.25 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $4.25 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $4.25 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $4.25 |
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 Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $5.86 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $5.81 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $5.81 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $5.81 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$15.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $5.96 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $4.25 |
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 Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $4.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $4.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $4.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$15.50 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $4.25 |
Browse Plan Formulary |
Paramount Elite - Standard Medical and Drug (HMO)
|
$23.00 |
$100* | No additional gap coverage, only the Donut Hole Discount | 2* |
Non-Preferred Generic |
$15.00 | $30.00 | None | $9.53 |
Browse Plan Formulary |
HumanaChoice R5826-006 (Regional PPO)
|
$28.20 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $8.92 |
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 |
PriorityMedicare Value (HMO-POS)
|
$52.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$12.00 | $30.00 | None | $5.81 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$55.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$6.00 | $15.00 | None | $9.94 |
Browse Plan Formulary |
HumanaChoice H5216-009 (PPO)
|
$67.00 |
$320* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$6.00 | $0.00 | None | $9.19 |
Browse Plan Formulary |
Paramount Elite - Enhanced Medical and Drug (HMO)
|
$68.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$8.00 | $16.00 | None | $9.53 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$71.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$12.00 | $30.00 | None | $5.96 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$71.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$12.00 | $30.00 | None | $5.86 |
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)
|
$71.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$12.00 | $30.00 | None | $5.81 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$71.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$12.00 | $30.00 | None | $5.81 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$71.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$12.00 | $30.00 | None | $5.81 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$75.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $4.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$75.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $4.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$75.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $4.25 |
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)
|
$75.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $4.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$75.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $4.25 |
Browse Plan Formulary |
Humana Gold Choice H8145-005 (PFFS)
|
$83.00 |
$320* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$6.00 | $0.00 | None | $8.55 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$106.00 |
$100* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$2.00 | $5.00 | None | $9.94 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$3.00 | $7.50 | None | $4.25 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$3.00 | $7.50 | None | $4.25 |
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)
|
$113.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$3.00 | $7.50 | None | $4.25 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$3.00 | $7.50 | None | $4.25 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$3.00 | $7.50 | None | $4.25 |
Browse Plan Formulary |
Alliance Medicare PPO (PPO)
|
$126.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$2.00 | $5.00 | None | $9.94 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$136.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $5.81 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$145.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$9.00 | $22.50 | None | $5.81 |
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)
|
$145.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$9.00 | $22.50 | None | $5.81 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$145.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$9.00 | $22.50 | None | $5.86 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$145.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$9.00 | $22.50 | None | $5.81 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$145.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$9.00 | $22.50 | None | $5.96 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$162.00 |
$95* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$3.00 | $7.50 | None | $4.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$162.00 |
$95* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$3.00 | $7.50 | None | $4.25 |
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 Signature (PPO)
|
$162.00 |
$95* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$3.00 | $7.50 | None | $4.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$162.00 |
$95* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$3.00 | $7.50 | None | $4.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$162.00 |
$95* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$3.00 | $7.50 | None | $4.25 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$192.00 |
$50* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$4.00 | $10.00 | None | $9.94 |
Browse Plan Formulary |
Alliance Medicare PPO (PPO)
|
$210.00 |
$150* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$4.00 | $10.00 | None | $9.94 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$238.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$3.00 | $7.50 | None | $4.25 |
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)
|
$238.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$3.00 | $7.50 | None | $4.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$238.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$3.00 | $7.50 | None | $4.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$238.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$3.00 | $7.50 | None | $4.25 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$238.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$3.00 | $7.50 | None | $4.25 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$262.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$3.00 | $7.50 | None | $4.25 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$262.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$3.00 | $7.50 | None | $4.25 |
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 Prestige (HMO-POS)
|
$262.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$3.00 | $7.50 | None | $4.25 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$262.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$3.00 | $7.50 | None | $4.25 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$262.00 |
$0 | Yes, but No Gap Coverage for this drug. | 1 |
Preferred Generic |
$3.00 | $7.50 | None | $4.25 |
Browse Plan Formulary |