Ampicillin 2000 MG / Sulbactam 1000 MG Injection (NDC: 55150011720)
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 |
BCN Advantage HMO HealthyValue (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $89.60 |
Browse Plan Formulary |
BCN Advantage HMO HealthyValue (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $95.91 |
Browse Plan Formulary |
BCN Advantage HMO HealthyValue (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $98.95 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $98.95 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $89.60 |
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 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $98.95 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $95.15 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$395 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $98.95 |
Browse Plan Formulary |
MeridianCare Essential (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | n/a | None | $98.95 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | n/a | None | $103.91 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | n/a | None | $98.72 |
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 Key (HMO-POS)
|
$0.00 |
$150* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | n/a | None | $90.73 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | n/a | None | $103.91 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$150* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | n/a | None | $104.74 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$9.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | n/a | None | $103.91 |
Browse Plan Formulary |
Aetna Medicare Value Plan (PPO)
|
$12.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $110.35 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$16.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $95.91 |
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)
|
$16.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $98.95 |
Browse Plan Formulary |
BCN Advantage HMO HealthySaver (HMO)
|
$16.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $89.60 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$13.00 | n/a | None | $104.74 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$13.00 | n/a | None | $103.91 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$13.00 | n/a | None | $98.72 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$13.00 | n/a | None | $90.73 |
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 |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$13.00 | n/a | None | $103.91 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$19.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $89.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$19.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $89.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$19.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $95.15 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$19.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $98.49 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$19.50 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $98.95 |
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 |
HumanaChoice R3887-002 (Regional PPO)
|
$20.00 |
$405 |
to be determined |
4 |
Non-Preferred Drug |
25% | 25% | None | $68.87 |
Browse Plan Formulary |
MeridianCare Extra (HMO SNP)
|
$33.30 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | n/a | None | $98.95 |
Browse Plan Formulary |
BCN Advantage HMO MyChoice Wellness (HMO)
|
$35.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $98.95 |
Browse Plan Formulary |
BCN Advantage HMO MyChoice Wellness (HMO)
|
$35.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $89.60 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$37.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | None | $103.91 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$37.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | None | $98.72 |
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 Merit (PPO)
|
$37.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | None | $90.73 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$37.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | None | $103.91 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$37.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | n/a | None | $104.74 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$44.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $98.49 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$44.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $98.95 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$44.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $89.60 |
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)
|
$44.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $89.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$44.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $95.15 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$46.00 |
$50 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $110.35 |
Browse Plan Formulary |
HumanaChoice H5216-009 (PPO)
|
$75.00 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $68.90 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$90.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | n/a | None | $103.91 |
Browse Plan Formulary |
Humana Gold Choice H8145-006 (PFFS)
|
$97.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $74.49 |
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)
|
$113.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $98.95 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $95.15 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $98.95 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $98.95 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $89.60 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$129.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | n/a | None | $103.91 |
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)
|
$129.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | n/a | None | $104.74 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$129.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | n/a | None | $103.91 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$129.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | n/a | None | $98.72 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$129.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | n/a | None | $90.73 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$129.50 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $89.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$129.50 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $95.15 |
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)
|
$129.50 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $98.49 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$129.50 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $98.95 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$129.50 |
$105 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $89.60 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$200.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $98.95 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$200.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $98.95 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$200.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $89.60 |
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)
|
$200.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $98.95 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$200.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $95.15 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$209.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $98.95 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$209.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $89.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$209.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $89.60 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$209.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $95.15 |
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)
|
$209.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
45% | 45% | None | $98.49 |
Browse Plan Formulary |