amphotericin b 50mg/10mL 10 mL in 1 VIAL (10 mL in 1 VIAL ) (NDC: 39822105505)
2017 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 Better Health Premier Plan (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | n/a | P | $35.22 |
Browse Plan Formulary |
AmeriHealth Caritas VIP Care Plus (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | n/a | P | $37.70 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$18.00 | n/a | P | $34.76 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$18.00 | n/a | P | $34.76 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$18.00 | n/a | P | $34.85 |
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 Basic (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$18.00 | n/a | P | $34.76 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$18.00 | n/a | P | $34.76 |
Browse Plan Formulary |
Fidelis SecureLife (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | n/a | P | $33.80 |
Browse Plan Formulary |
HAP Midwest MI Health Link (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | n/a | P | $37.09 |
Browse Plan Formulary |
HAP Senior Plus (HMO)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | n/a | P | $41.12 |
Browse Plan Formulary |
Harbor Medicare (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | n/a | P | $39.80 |
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 |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Generic Drugs |
0% | n/a | P | $35.00 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | P | $33.85 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | P | $33.85 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | P | $33.85 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | P | $20.73 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | P | $33.85 |
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 |
Molina Medicare Options Plus (HMO SNP)
|
$5.10 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
46% | n/a | P | $35.01 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | P | $33.85 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | P | $33.85 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | P | $33.85 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | P | $33.85 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | P | $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 |
BCN Advantage HMO HealthySaver (HMO)
|
$25.00 |
$100* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$20.00 | n/a | P | $34.85 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$25.00 |
$100* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$20.00 | n/a | P | $34.76 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$25.00 |
$100* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$20.00 | n/a | P | $34.76 |
Browse Plan Formulary |
HumanaChoice R5826-006 (Regional PPO)
|
$25.50 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
25% | 25% | P | $48.86 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$25.50 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | P | $34.86 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$25.50 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | P | $34.85 |
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)
|
$25.50 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | P | $34.86 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$25.50 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | P | $34.86 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$25.50 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | P | $34.86 |
Browse Plan Formulary |
HAP Midwest Health Plan (HMO SNP)
|
$34.20 |
$370 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
25% | n/a | P | $37.09 |
Browse Plan Formulary |
HAP Senior Plus Option 1 (HMO-POS)
|
$48.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | n/a | P | $41.12 |
Browse Plan Formulary |
BCN Advantage HMO ConnectedCare (HMO)
|
$58.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | n/a | P | $34.85 |
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 |
Harbor Medicare Select (HMO)
|
$60.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | n/a | P | $39.80 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$66.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | n/a | P | $20.72 |
Browse Plan Formulary |
Humana Gold Plus H8908-001 (HMO)
|
$73.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $48.86 |
Browse Plan Formulary |
HAP Senior Plus Henry Ford Tiered Access (HMO)
|
$77.00 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | n/a | P | $41.12 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | P | $34.06 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | P | $34.06 |
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)
|
$95.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | P | $34.06 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | P | $34.06 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$95.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | P | $20.72 |
Browse Plan Formulary |
HAP Senior Plus Option 2 (HMO-POS)
|
$97.00 |
$100* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | n/a | P | $41.12 |
Browse Plan Formulary |
HumanaChoice H5216-011 (PPO)
|
$108.00 |
$400 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | P | $48.86 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$111.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | P | $34.86 |
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 |
Medicare Plus Blue PPO Vitality (PPO)
|
$111.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | P | $34.86 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$111.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | P | $34.86 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$111.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | P | $34.85 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$111.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | n/a | P | $34.86 |
Browse Plan Formulary |
HAP Senior Plus Option 1 (PPO)
|
$124.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | n/a | P | $41.12 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$145.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | n/a | P | $20.72 |
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 |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$166.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | n/a | P | $34.76 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$166.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | n/a | P | $34.76 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$166.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | n/a | P | $34.76 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$166.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | n/a | P | $34.76 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$166.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | n/a | P | $34.85 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$174.00 |
$105* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | n/a | P | $34.86 |
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 |
Medicare Plus Blue PPO Signature (PPO)
|
$174.00 |
$105* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | n/a | P | $34.86 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$174.00 |
$105* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | n/a | P | $34.86 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$174.00 |
$105* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | n/a | P | $34.86 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$174.00 |
$105* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | n/a | P | $34.85 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$201.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | n/a | P | $34.06 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$201.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | n/a | P | $20.72 |
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 |
PriorityMedicare Select (PPO)
|
$201.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | n/a | P | $34.06 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$201.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | n/a | P | $34.06 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$201.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | n/a | P | $34.06 |
Browse Plan Formulary |
HAP Senior Plus Option 2 (PPO)
|
$208.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$10.00 | n/a | P | $41.12 |
Browse Plan Formulary |
HAP Senior Plus Option 3 (HMO-POS)
|
$218.00 |
$50* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$10.00 | n/a | P | $41.12 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$303.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | n/a | P | $34.76 |
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)
|
$303.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | n/a | P | $34.76 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$303.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | n/a | P | $34.76 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$303.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | n/a | P | $34.85 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$303.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | n/a | P | $34.76 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$314.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$14.00 | n/a | P | $34.86 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$314.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$14.00 | n/a | P | $34.86 |
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 |
Medicare Plus Blue PPO Assure (PPO)
|
$314.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$14.00 | n/a | P | $34.85 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$314.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$14.00 | n/a | P | $34.86 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$314.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$14.00 | n/a | P | $34.86 |
Browse Plan Formulary |