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)
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 Value Plan (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
50% | 50% | None | $47.49 |
Browse Plan Formulary |
Anthem Dual Advantage (HMO SNP)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $45.47 |
Browse Plan Formulary |
Anthem Senior Advantage Basic (HMO)
|
$0.00 |
$153 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $45.47 |
Browse Plan Formulary |
CareSource MyCare Ohio (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic Drugs |
0% | 0% | None | $45.34 |
Browse Plan Formulary |
Gateway Health Medicare Assured Select (HMO)
|
$0.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$12.00 | $24.00 | None | $41.41 |
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 |
HealthSpan Medicare Standard (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$14.00 | $28.00 | None | $41.92 |
Browse Plan Formulary |
Humana Gold Plus H8953-006 (HMO)
|
$0.00 |
$320 |
Yes, this drug has Gap Coverage. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $56.90 |
Browse Plan Formulary |
PrimeTime Health Plan Aultimate (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$15.00 | $45.00 | None | $39.58 |
Browse Plan Formulary |
SecureCare - Option IV (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None | $45.44 |
Browse Plan Formulary |
SummaCare Medicare Topaz (HMO)
|
$0.00 |
$100* |
to be determined |
2* |
Tier 2 |
$15.00 | $37.50 | None | $42.19 |
Browse Plan Formulary |
UnitedHealthcare Connected for MyCareOhio (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic Drugs |
0% | 0% | None | $41.56 |
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 |
HealthSpan Medicare Core 2 (HMO)
|
$2.00 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $41.92 |
Browse Plan Formulary |
HealthSpan Medicare Plus IV (Cost)
|
$27.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$30.00 | $60.00 | None | $41.92 |
Browse Plan Formulary |
Buckeye Health Plan Advantage (HMO SNP)
|
$28.60 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $42.03 |
Browse Plan Formulary |
Gateway Health Medicare Assured Diamond (HMO SNP)
|
$28.60 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | n/a | None | $42.32 |
Browse Plan Formulary |
Gateway Health Medicare Assured Ruby (HMO SNP)
|
$28.60 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | n/a | None | $42.32 |
Browse Plan Formulary |
SecureCare SNP (HMO SNP)
|
$28.60 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $45.44 |
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 |
PrimeTime Health Plan Classic (HMO-POS)
|
$29.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$8.00 | $24.00 | None | $39.58 |
Browse Plan Formulary |
SummaCare Medicare Ruby (HMO)
|
$32.00 |
$0 |
to be determined |
2 |
Tier 2 |
$10.00 | $25.00 | None | $42.19 |
Browse Plan Formulary |
HumanaChoice R5826-007 (Regional PPO)
|
$32.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $56.90 |
Browse Plan Formulary |
HealthSpan Medicare Plus III (Cost)
|
$37.10 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None | $41.87 |
Browse Plan Formulary |
Gateway Health Medicare Assured Gold (HMO SNP)
|
$39.80 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $41.41 |
Browse Plan Formulary |
Blue Medicare Access Value (Regional PPO)
|
$40.80 |
$115 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $45.47 |
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 |
HealthSpan Medicare Plus II (Cost)
|
$42.10 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$14.00 | $28.00 | None | $41.92 |
Browse Plan Formulary |
HealthSpan Medicare Enhanced (HMO)
|
$52.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$14.00 | $28.00 | None | $41.92 |
Browse Plan Formulary |
HealthSpan Medicare Plus I - B only (Cost)
|
$52.10 |
$0 |
to be determined |
2 |
Tier 2 |
$14.00 | $28.00 | None | $41.92 |
Browse Plan Formulary |
Gateway Health Medicare Assured Choice (HMO)
|
$57.80 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None | $41.41 |
Browse Plan Formulary |
Anthem Senior Advantage Plus (HMO)
|
$64.00 |
$123 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $45.47 |
Browse Plan Formulary |
SecureCare - Option II (HMO)
|
$66.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$15.00 | $30.00 | None | $45.44 |
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 |
PrimeTime Health Plan Plus (HMO-POS)
|
$69.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$8.00 | $24.00 | None | $39.58 |
Browse Plan Formulary |
Anthem Medicare Preferred Standard (PPO)
|
$71.00 |
$165 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $45.47 |
Browse Plan Formulary |
Anthem Medicare Preferred Standard (PPO)
|
$71.00 |
$165 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $45.47 |
Browse Plan Formulary |
HumanaChoice H6609-082 (PPO)
|
$72.00 |
$320 |
Yes, this drug has Gap Coverage. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $56.90 |
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 | $41.41 |
Browse Plan Formulary |
SummaCare Medicare Sapphire (HMO-POS)
|
$78.00 |
$0 |
to be determined |
2 |
Tier 2 |
$15.00 | $37.50 | None | $42.19 |
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 |
Gateway Health Medicare Assured Prime (HMO)
|
$82.80 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$20.00 | $40.00 | None | $41.41 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$100.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
50% | 50% | None | $47.49 |
Browse Plan Formulary |
Aetna Medicare Select Plus Plan (PPO)
|
$139.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
50% | 50% | None | $47.49 |
Browse Plan Formulary |
HealthSpan Medicare Plus I (Cost)
|
$148.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Tier 2 |
$14.00 | $28.00 | None | $41.92 |
Browse Plan Formulary |
SummaCare Medicare Emerald (HMO-POS)
|
$182.00 |
$0 |
to be determined |
2 |
Tier 2 |
$10.00 | $25.00 | None | $42.19 |
Browse Plan Formulary |