AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin] (30 BOT) (NDC: 00781187431)
2019 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 (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | None | $60.45 |
Browse Plan Formulary |
Advantra Silver Plus (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | None | $40.47 |
Browse Plan Formulary |
Aetna Medicare Silver (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$5.00 | $10.00 | None | $47.14 |
Browse Plan Formulary |
Community Blue Medicare HMO Signature (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$5.00 | $12.00 | None | $125.18 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $124.73 |
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 Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $126.92 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $124.93 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $127.34 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $125.96 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $126.69 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $127.67 |
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 Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $126.98 |
Browse Plan Formulary |
Geisinger Gold Classic Essential Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $126.86 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $124.73 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $126.92 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $124.93 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $127.34 |
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 | $30.00 | None | $125.96 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $126.69 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $127.67 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $126.98 |
Browse Plan Formulary |
Geisinger Gold Preferred Complete Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $126.86 |
Browse Plan Formulary |
HumanaChoice R0923-002 (Regional PPO)
|
$21.90 |
$0 |
to be determined |
2 |
Generic |
$20.00 | $0.00 | None | $128.48 |
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)
|
$22.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $118.24 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$27.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $40.00 | None | $125.75 |
Browse Plan Formulary |
Community Blue Medicare PPO Signature (PPO)
|
$27.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $40.00 | None | $124.96 |
Browse Plan Formulary |
Humana Value Plus H5525-039 (PPO)
|
$27.60 |
$260* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$13.00 | $0.00 | None | $128.59 |
Browse Plan Formulary |
Advantra Silver (PPO)
|
$29.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | None | $60.45 |
Browse Plan Formulary |
UPMC for Life PPO High Deductible with Rx (PPO)
|
$35.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $117.21 |
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 |
Allwell Dual Medicare (HMO SNP)
|
$37.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
All Formulary Drugs |
$0.00 | $0.00 | None | $111.15 |
Browse Plan Formulary |
Geisinger Gold Secure Rx (HMO SNP)
|
$37.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
1 |
All Formulary Drugs |
15% | 15% | None | $126.53 |
Browse Plan Formulary |
UPMC for Life Dual (HMO SNP)
|
$37.00 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
46% | 46% | None | $116.20 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $126.98 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $126.86 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $124.73 |
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)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $126.92 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $124.93 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $127.34 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $125.96 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $126.69 |
Browse Plan Formulary |
Geisinger Gold Classic Complete Rx (HMO)
|
$38.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $127.67 |
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 Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $124.93 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $127.34 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $125.96 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $126.69 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $127.67 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $126.98 |
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 Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $126.86 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $124.73 |
Browse Plan Formulary |
Geisinger Gold Preferred Enhanced Rx (PPO)
|
$45.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $126.92 |
Browse Plan Formulary |
Aetna Medicare Silver Plan (HMO)
|
$47.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | None | $53.69 |
Browse Plan Formulary |
Humana Gold Choice H8145-052 (PFFS)
|
$58.00 |
$360* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$17.00 | $0.00 | None | $128.44 |
Browse Plan Formulary |
Advantra Gold (HMO)
|
$59.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | None | $60.45 |
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 |
Security Blue HMO-POS ValueRx (HMO-POS)
|
$60.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $40.00 | None | $127.13 |
Browse Plan Formulary |
Freedom Blue PPO ValueRx (PPO)
|
$74.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $40.00 | None | $127.13 |
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 | $285.00 | None | $118.24 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$112.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $126.98 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$112.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $126.86 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$112.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $124.73 |
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 Preferred Advantage Rx (PPO)
|
$112.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $126.92 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$112.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $124.93 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$112.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $127.34 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$112.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $125.96 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$112.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $126.69 |
Browse Plan Formulary |
Geisinger Gold Preferred Advantage Rx (PPO)
|
$112.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $127.67 |
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 Select (PPO)
|
$133.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$15.00 | $40.00 | None | $127.13 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$135.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $117.21 |
Browse Plan Formulary |
Aetna Medicare Gold Plan (PPO)
|
$147.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$0.00 | $0.00 | None | $53.69 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$158.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $126.69 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$158.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $127.67 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$158.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $126.98 |
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)
|
$158.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $126.86 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$158.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $126.92 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$158.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $124.73 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$158.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $127.34 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$158.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $125.96 |
Browse Plan Formulary |
Geisinger Gold Classic Advantage Rx (HMO)
|
$158.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$20.00 | $30.00 | None | $124.93 |
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 |
Security Blue HMO-POS Standard (HMO-POS)
|
$187.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$13.00 | $32.50 | None | $124.95 |
Browse Plan Formulary |
Security Blue HMO-POS Deluxe (HMO-POS)
|
$227.50 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$13.00 | $32.50 | None | $124.95 |
Browse Plan Formulary |
Freedom Blue PPO Classic (PPO)
|
$269.50 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$15.00 | $40.00 | None | $127.13 |
Browse Plan Formulary |
UPMC for Life HMO Rx Enhanced (HMO)
|
$290.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$95.00 | $285.00 | None | $118.08 |
Browse Plan Formulary |