CEFTAZIDIME FOR INJECTION 6GM/VIAL 6 X 6 CRTN (6 X 6 CRTN) (NDC: 25021012999)
2018 Medicare Prescription Drug Plan (MAPD) Information
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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 (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $164.74 |
Browse Plan Formulary |
Aetna Medicare PinnacleHealth Prime Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $158.35 |
Browse Plan Formulary |
BlueJourney Essential (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $45.00 | None | $158.23 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$90.00 | $270.00 | None | $175.36 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$90.00 | $270.00 | None | $126.54 |
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 |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$90.00 | $270.00 | None | $126.54 |
Browse Plan Formulary |
Geisinger Gold Essential Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $152.83 |
Browse Plan Formulary |
Geisinger Gold Essential Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $152.83 |
Browse Plan Formulary |
Geisinger Gold Essential Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $154.07 |
Browse Plan Formulary |
Geisinger Gold Essential Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $149.87 |
Browse Plan Formulary |
Geisinger Gold Essential Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $152.83 |
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 Essential Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $149.87 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $152.83 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $152.83 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $152.83 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $154.07 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $149.87 |
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 Complete Rx (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $149.87 |
Browse Plan Formulary |
Humana Gold Plus H6622-035 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $222.73 |
Browse Plan Formulary |
Humana Gold Plus H6622-043 (HMO)
|
$0.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $157.70 |
Browse Plan Formulary |
Vibra Health Plan Essential Coverage (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$15.00 | n/a | None | $149.85 |
Browse Plan Formulary |
AdvantraOne (PPO)
|
$19.00 |
$195 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $158.95 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$19.00 |
$405 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | n/a | None | $149.81 |
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 |
UPMC for Life HMO Deductible with Rx (HMO)
|
$20.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | n/a | None | $161.27 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete ONE (HMO SNP)
|
$23.50 |
$405 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
$0.00 | n/a | None | $149.81 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H6622-038 (HMO SNP)
|
$25.00 |
$230 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $157.70 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$27.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$90.00 | $270.00 | None | $175.36 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$27.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$90.00 | $270.00 | None | $130.25 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$27.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$90.00 | $270.00 | None | $126.54 |
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 Assisted Living Plan (PPO SNP)
|
$29.30 |
$200 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $153.09 |
Browse Plan Formulary |
HumanaChoice R0923-002 (Regional PPO)
|
$29.40 |
$315 | to be determined | 4 |
Non-Preferred Drug |
$99.00 | $287.00 | None | $157.70 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan 2 (PPO SNP)
|
$32.70 |
$405 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | n/a | None | $153.09 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$35.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | n/a | None | $161.27 |
Browse Plan Formulary |
Advantra Silver Plus (HMO)
|
$36.00 |
$95 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $164.74 |
Browse Plan Formulary |
HumanaChoice H5525-006 (PPO)
|
$37.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $157.70 |
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 |
UPMC for Life Dual (HMO SNP)
|
$37.10 |
$405 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
46% | n/a | None | $151.12 |
Browse Plan Formulary |
AmeriHealth Caritas VIP Care (HMO SNP)
|
$37.20 |
$405 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | n/a | None | $158.61 |
Browse Plan Formulary |
Gateway Health Medicare Assured Diamond (HMO SNP)
|
$37.20 |
$405 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | n/a | None | $158.04 |
Browse Plan Formulary |
Gateway Health Medicare Assured Ruby (HMO SNP)
|
$37.20 |
$405 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | n/a | None | $158.04 |
Browse Plan Formulary |
Geisinger Gold Secure Rx (HMO SNP)
|
$37.20 |
$405 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | n/a | None | $151.38 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $155.02 |
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)
|
$38.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $149.87 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $154.07 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $155.02 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $155.02 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $149.87 |
Browse Plan Formulary |
BlueJourney Value (HMO)
|
$48.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$12.00 | $36.00 | None | $158.23 |
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 |
Vibra Health Plan Enhanced Coverage (PPO)
|
$55.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | n/a | None | $149.85 |
Browse Plan Formulary |
Aetna Medicare Silver Plan (HMO)
|
$56.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $159.86 |
Browse Plan Formulary |
BlueJourney Classic (PPO)
|
$62.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $45.00 | None | $158.23 |
Browse Plan Formulary |
Humana Gold Choice H8145-052 (PFFS)
|
$63.00 |
$360 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $222.73 |
Browse Plan Formulary |
Freedom Blue PPO ValueRx (PPO)
|
$73.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $115.00 | None | $161.27 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$77.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $152.83 |
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)
|
$77.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $154.07 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$77.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $149.87 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$77.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $152.83 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$77.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $152.83 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$77.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $149.87 |
Browse Plan Formulary |
UPMC for Life HMO Rx (HMO)
|
$81.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | n/a | None | $161.27 |
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 |
Advantra Silver Plus (PPO)
|
$86.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $164.74 |
Browse Plan Formulary |
HumanaChoice H5216-120 (PPO)
|
$117.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$97.00 | $281.00 | None | $157.70 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$136.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $164.74 |
Browse Plan Formulary |
BlueJourney Premier (HMO)
|
$148.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $30.00 | None | $158.23 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$154.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $149.87 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$154.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $155.02 |
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)
|
$154.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $155.02 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$154.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $154.07 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$154.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $149.87 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$154.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$20.00 | n/a | None | $155.02 |
Browse Plan Formulary |
Aetna Medicare Gold Plan (PPO)
|
$156.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $159.86 |
Browse Plan Formulary |
BlueJourney Prime (PPO)
|
$169.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $45.00 | None | $158.23 |
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 |
Freedom Blue PPO Standard (PPO)
|
$188.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | $40.00 | None | $161.27 |
Browse Plan Formulary |
Freedom Blue PPO Deluxe (PPO)
|
$291.50 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$15.00 | $40.00 | None | $161.27 |
Browse Plan Formulary |