Piperacillin and Tazobactam 4; 0.5g/1; g/1 10 VIAL, SINGLE-USE per CARTON / 1 INJECTION, POWDER, L (10 VIAL, SINGLE-USE in 1 ) (NDC: 00409337904)
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 |
AARP MedicareComplete (HMO)
|
$0.00 |
$165 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $69.37 |
Browse Plan Formulary |
Advantra (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
50% | 50% | None | $85.47 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
50% | 50% | None | $84.39 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $87.78 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $87.78 |
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 |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $87.78 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $87.78 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $87.78 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $87.78 |
Browse Plan Formulary |
Amerivantage Specialty + Rx (HMO SNP)
|
$0.00 |
$320 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $87.78 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Basic (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$6.00 | $33.00 | None | $121.45 |
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 |
Care Improvement Plus Dual Advantage (Regional PPO SNP)
|
$0.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | None | $69.37 |
Browse Plan Formulary |
Care Improvement Plus Gold Rx (PPO SNP)
|
$0.00 |
$315 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $69.37 |
Browse Plan Formulary |
Care Improvement Plus Gold Rx (Regional PPO SNP)
|
$0.00 |
$315 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $69.37 |
Browse Plan Formulary |
Care Improvement Plus Silver Rx (Regional PPO SNP)
|
$0.00 |
$307 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
25% | 25% | None | $69.37 |
Browse Plan Formulary |
Cigna-HealthSpring Preferred (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$60.00 | $180.00 | None | $71.84 |
Browse Plan Formulary |
Cigna-HealthSpring Preferred (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Brand |
$60.00 | $180.00 | None | $71.84 |
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 |
Humana Gold Plus H4510-028 (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 4 |
Non-Preferred Brand |
$85.00 | $245.00 | None | $114.32 |
Browse Plan Formulary |
KelseyCare Advantage Rx (HMO)
|
$0.00 |
$50 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$30.00 | n/a | None | $79.51 |
Browse Plan Formulary |
Memorial Hermann Advantage (HMO)
|
$0.00 |
$100* | Yes, but No Gap Coverage for this drug. | 2* |
Non-Preferred Generic |
$5.00 | $10.00 | None | $78.64 |
Browse Plan Formulary |
Memorial Hermann Advantage (PPO)
|
$0.00 |
$100* | Yes, but No Gap Coverage for this drug. | 2* |
Non-Preferred Generic |
$5.00 | $10.00 | None | $78.64 |
Browse Plan Formulary |
TexanPlus Choice (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$0.00 | $0.00 | None | $87.42 |
Browse Plan Formulary |
TexanPlus Classic (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$0.00 | $0.00 | None | $87.42 |
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 |
WellCare Dividend (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $84.31 |
Browse Plan Formulary |
WellCare Value (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $84.31 |
Browse Plan Formulary |
HumanaChoice R5826-091 (Regional PPO)
|
$15.00 |
$320 | Yes, this drug has Gap Coverage. | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $114.32 |
Browse Plan Formulary |
Care Improvement Plus Medicare Advantage (PPO)
|
$19.00 |
$315 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $69.37 |
Browse Plan Formulary |
Care Improvement Plus Medicare Advantage (Regional PPO)
|
$19.00 |
$315 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $69.37 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$21.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$90.00 | $225.00 | None | $84.31 |
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 |
Humana Gold Plus SNP-DE H4510-021 (HMO SNP)
|
$26.20 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | $0.00 | None | $114.32 |
Browse Plan Formulary |
Cigna-HealthSpring TotalCare (HMO SNP)
|
$27.30 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $71.75 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$27.30 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | None | $69.37 |
Browse Plan Formulary |
HumanaChoice R5826-012 (Regional PPO)
|
$34.00 |
$0 | Yes, this drug has Gap Coverage. | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $114.32 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Choice Plus (PPO)
|
$35.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$6.00 | $33.00 | None | $121.45 |
Browse Plan Formulary |
Advantra (PPO)
|
$41.00 |
$320 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $84.93 |
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 Medicare Advantage Choice Premier (PPO)
|
$55.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$6.00 | $33.00 | None | $121.45 |
Browse Plan Formulary |
HumanaChoice H6609-108 (PPO)
|
$66.00 |
$0 | Yes, this drug has Gap Coverage. | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $114.32 |
Browse Plan Formulary |
KelseyCare Advantage Rx+Choice (HMO-POS)
|
$77.00 |
$50 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$30.00 | n/a | None | $79.51 |
Browse Plan Formulary |
Humana Gold Choice H8145-084 (PFFS)
|
$89.00 |
$200 | Yes, this drug has Gap Coverage. | 4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $114.32 |
Browse Plan Formulary |
KelseyCare Advantage Rx Premier (HMO)
|
$221.00 |
$50 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$20.00 | n/a | None | $79.51 |
Browse Plan Formulary |