AZITHROMYCIN 1 GM PWD PACKET (3 EA ) (NDC: 59762305102)
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 |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | None | $75.29 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | None | $75.29 |
Browse Plan Formulary |
Anthem Select Advantage (HMO)
|
$0.00 |
$150* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$21.00 | $42.00 | None | $58.17 |
Browse Plan Formulary |
Anthem Select Advantage (HMO)
|
$0.00 |
$150* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$21.00 | $42.00 | None | $58.17 |
Browse Plan Formulary |
Blue Cross Senior Secure Plan I (HMO)
|
$0.00 |
$50* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$28.00 | $56.00 | None | $58.17 |
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 Cross Senior Secure Plan I (HMO)
|
$0.00 |
$50* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Non-Preferred Generic |
$28.00 | $56.00 | None | $58.17 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None | $74.58 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | None | $74.58 |
Browse Plan Formulary |
Blue Shield 65 Plus Choice Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$3.00 | $6.00 | None | $74.58 |
Browse Plan Formulary |
Bridges Drug Savings (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$9.00 | $25.00 | None | $73.56 |
Browse Plan Formulary |
Bridges Drug Savings (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$9.00 | $25.00 | None | $73.56 |
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 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | Q:2 /30Days | $76.68 |
Browse Plan Formulary |
Care1st AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$5.00 | $10.00 | Q:2 /30Days | $76.68 |
Browse Plan Formulary |
Care1st Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic Drugs |
0% | 0% | Q:2 /30Days | $76.70 |
Browse Plan Formulary |
Care1st Cal MediConnect Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic Drugs |
0% | 0% | Q:2 /30Days | $76.70 |
Browse Plan Formulary |
Care1st TotalDual Plan (HMO SNP)
|
$0.00 |
$320 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
25% | 25% | Q:2 /30Days | $76.70 |
Browse Plan Formulary |
Citizens Choice Health Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$3.00 | $6.00 | None | $67.78 |
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 |
Citizens Choice Health Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$3.00 | $6.00 | None | $67.78 |
Browse Plan Formulary |
Classic Care (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$9.00 | $25.00 | None | $73.56 |
Browse Plan Formulary |
Classic Care (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$9.00 | $25.00 | None | $73.56 |
Browse Plan Formulary |
Dual Coverage (HMO SNP)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
25% | 25% | None | $73.56 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $73.21 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $73.21 |
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 |
Easy Choice Freedom Plan (HMO SNP)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$29.00 | $72.50 | None | $73.21 |
Browse Plan Formulary |
Golden State Medicare Health Plan, Golden (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$10.00 | $20.00 | None | $62.32 |
Browse Plan Formulary |
Golden State Medicare Health Plan, Golden (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$10.00 | $20.00 | None | $62.33 |
Browse Plan Formulary |
Healthy Heart Drug Savings (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$9.00 | $25.00 | None | $73.56 |
Browse Plan Formulary |
Healthy Heart Drug Savings (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$9.00 | $25.00 | None | $73.56 |
Browse Plan Formulary |
Hope Drug Savings (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$9.00 | $25.00 | None | $73.56 |
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 |
Hope Drug Savings (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$9.00 | $25.00 | None | $73.56 |
Browse Plan Formulary |
Humana Gold Plus H0108-011 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$10.00 | $0.00 | None | $90.19 |
Browse Plan Formulary |
In Control Drug Savings (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$9.00 | $25.00 | None | $73.56 |
Browse Plan Formulary |
In Control Drug Savings (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$9.00 | $25.00 | None | $73.56 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$45.00 | $90.00 | None | $86.72 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$45.00 | $90.00 | None | $86.72 |
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 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $87.20 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage LA, Orange Co. (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $87.20 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic Drugs |
0% | 0% | None | $66.56 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic Drugs |
0% | 0% | None | $66.56 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$0.00 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Generic |
$0.00 | $0.00 | None | $66.56 |
Browse Plan Formulary |
Platinum Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $67.43 |
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 |
Platinum Plan (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $67.43 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $86.72 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$14.80 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$8.00 | $24.00 | None | $75.29 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$15.30 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $86.72 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$21.90 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Generic |
$0.00 | $0.00 | None | $66.56 |
Browse Plan Formulary |
Humana Gold Plus H0108-050 (HMO)
|
$22.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None | $90.29 |
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 |
Easy Choice Freedom Plan (HMO SNP)
|
$23.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$29.00 | $72.50 | None | $73.21 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$23.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$29.00 | $72.50 | None | $73.21 |
Browse Plan Formulary |
Easy Choice Plus Plan (HMO)
|
$23.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$29.00 | $72.50 | None | $73.21 |
Browse Plan Formulary |
Care1st TotalDual Plan (HMO SNP)
|
$27.00 |
$320 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
25% | 25% | Q:2 /30Days | $76.70 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$28.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$8.00 | $24.00 | None | $75.29 |
Browse Plan Formulary |
Humana Gold Plus H0108-047 (HMO)
|
$28.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$2.00 | $0.00 | None | $90.19 |
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 |
Bridges Extra Care (HMO SNP)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
25% | 25% | None | $73.56 |
Browse Plan Formulary |
Bridges Extra Care (HMO SNP)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
25% | 25% | None | $73.56 |
Browse Plan Formulary |
CalPlus Plan (HMO)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $67.86 |
Browse Plan Formulary |
CalPlus Plan (HMO)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | 25% | None | $67.86 |
Browse Plan Formulary |
Coordinated Choice Plan (HMO)
|
$28.80 |
$320 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
25% | 25% | Q:2 /30Days | $76.72 |
Browse Plan Formulary |
Coordinated Choice Plan (HMO)
|
$28.80 |
$320 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
25% | 25% | Q:2 /30Days | $76.72 |
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 Coverage (HMO SNP)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
25% | 25% | None | $73.56 |
Browse Plan Formulary |
Harmony (HMO SNP)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $73.56 |
Browse Plan Formulary |
Harmony (HMO SNP)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $73.56 |
Browse Plan Formulary |
Healthy Heart Extra Care (HMO SNP)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
25% | 25% | None | $73.56 |
Browse Plan Formulary |
Healthy Heart Extra Care (HMO SNP)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
25% | 25% | None | $73.56 |
Browse Plan Formulary |
In Control Extra Care (HMO SNP)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
25% | 25% | None | $73.56 |
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 |
In Control Extra Care (HMO SNP)
|
$28.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
25% | 25% | None | $73.56 |
Browse Plan Formulary |