Nystatin 100000[USP'U]/g 1 TUBE per CARTON / 30 g in 1 TUBE (1 TUBE in 1 CARTON / 30 g ) (NDC: 51672128902)
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 Silver (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$12.00 | $30.00 | None | $20.51 |
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 | $20.75 |
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 | $20.64 |
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 | $20.76 |
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 | $20.73 |
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 | $19.14 |
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 | $20.76 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$20.00 | $60.00 | None | $19.13 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$20.00 | $60.00 | None | $20.71 |
Browse Plan Formulary |
Humana Gold Plus H6859-003 (HMO)
|
$0.00 |
$320* | Yes, but No Gap Coverage for this drug. | 2* |
Non-Preferred Generic |
$18.00 | $0.00 | None | $19.79 |
Browse Plan Formulary |
SeniorBlue - Option 3 (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
$12.00 | $36.00 | None | $21.37 |
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 |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$27.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $15.64 |
Browse Plan Formulary |
Geisinger Gold Preferred Essential Rx (PPO)
|
$31.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$20.00 | $60.00 | None | $18.51 |
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 | $19.77 |
Browse Plan Formulary |
AmeriHealth VIP Care (HMO SNP)
|
$33.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $17.71 |
Browse Plan Formulary |
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 | $21.65 |
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 | $21.65 |
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 Secure Rx (HMO SNP)
|
$33.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $20.32 |
Browse Plan Formulary |
HumanaChoice H5525-006 (PPO)
|
$34.00 |
$320* | Yes, but No Gap Coverage for this drug. | 2* |
Non-Preferred Generic |
$18.00 | $0.00 | None | $19.79 |
Browse Plan Formulary |
AARP MedicareComplete Choice Plan 1 (PPO)
|
$39.00 |
$230* | No additional gap coverage, only the Donut Hole Discount | 2* |
Non-Preferred Generic |
$8.00 | $16.00 | None | $16.26 |
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 | $19.79 |
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 | $21.65 |
Browse Plan Formulary |
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 | $20.77 |
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 |
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 | $20.69 |
Browse Plan Formulary |
AARP MedicareComplete Choice Plan 2 (PPO)
|
$59.00 |
$210* | No additional gap coverage, only the Donut Hole Discount | 2* |
Non-Preferred Generic |
$8.00 | $16.00 | None | $16.26 |
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 | $20.70 |
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 | $18.71 |
Browse Plan Formulary |
SeniorBlue - Option 2 (PPO)
|
$72.40 |
$0 | to be determined | 2 |
Tier 2 |
$17.00 | $51.00 | None | $21.37 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$75.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $20.71 |
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 Advantage Rx (PPO)
|
$75.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $19.13 |
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 | $21.65 |
Browse Plan Formulary |
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 | $18.71 |
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 | $20.75 |
Browse Plan Formulary |
SeniorBlue - Option 2 (HMO)
|
$117.50 |
$0 | to be determined | 2 |
Tier 2 |
$12.00 | $36.00 | None | $21.37 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$119.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $20.64 |
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)
|
$119.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $20.76 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$119.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $19.14 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$119.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $20.73 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$119.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$18.00 | $54.00 | None | $20.76 |
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 | $20.69 |
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 | $20.45 |
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 |
SeniorBlue - Option 1 (HMO)
|
$167.50 |
$0 | to be determined | 2 |
Tier 2 |
$9.00 | $27.00 | None | $21.37 |
Browse Plan Formulary |
SeniorBlue - Option 1 (PPO)
|
$191.90 |
$0 | to be determined | 2 |
Tier 2 |
$10.00 | $30.00 | None | $21.37 |
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 | $19.79 |
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 | $18.71 |
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 | $18.71 |
Browse Plan Formulary |