AMPICILLIN CAPSULES 500MG 100 BOT (100 BOT) (NDC: 00781214501)
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 |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$405* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$3.00 | $9.00 | None | $15.18 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$405* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$3.00 | $9.00 | None | $15.96 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$405* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$3.00 | $9.00 | None | $15.81 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$405* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$3.00 | $9.00 | None | $16.95 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$405* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$3.00 | $9.00 | None | $15.05 |
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 |
HAP Senior Plus (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $25.00 | None | $18.78 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$125* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | $0.00 | None | $18.07 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$125* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | $0.00 | None | $17.87 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$125* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | $0.00 | None | $18.48 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$125* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | $0.00 | None | $18.03 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$125* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$15.00 | $0.00 | None | $17.78 |
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 |
PriorityMedicare Ideal (PPO)
|
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$13.00 | $0.00 | None | $17.78 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$13.00 | $0.00 | None | $18.07 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$13.00 | $0.00 | None | $17.87 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$13.00 | $0.00 | None | $18.48 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$13.00 | $0.00 | None | $18.03 |
Browse Plan Formulary |
HAP Senior Plus Option 1 (PPO)
|
$15.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $25.00 | None | $18.78 |
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 |
Medicare Plus Blue PPO Essential (PPO)
|
$19.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | None | $15.07 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$19.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | None | $15.68 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$19.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | None | $15.59 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$19.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | None | $16.96 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$19.00 |
$405 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | None | $15.21 |
Browse Plan Formulary |
HumanaChoice H8087-001 (PPO)
|
$20.00 |
$195* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$2.00 | $0.00 | None | $19.18 |
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)
|
$20.50 |
$150* |
to be determined |
1* |
Preferred Generic |
$7.00 | $0.00 | None | $19.16 |
Browse Plan Formulary |
Humana Value Plus H8087-002 (PPO)
|
$23.90 |
$260* |
No additional gap coverage, only the Donut Hole Discount |
1* |
Preferred Generic |
$0.00 | $0.00 | None | $19.19 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$24.50 |
$415 |
No additional gap coverage, only the Donut Hole Discount |
2 |
All Formulary Drugs |
$0.00 | $0.00 | None | $18.91 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$42.00 |
$75 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $0.00 | None | $18.48 |
Browse Plan Formulary |
HAP Senior Plus Option 1 (HMO-POS)
|
$45.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $25.00 | None | $18.78 |
Browse Plan Formulary |
HAP Senior Plus Option 2 (PPO)
|
$55.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $25.00 | None | $18.78 |
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 |
HAP Senior Plus Option 2 (HMO-POS)
|
$75.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $25.00 | None | $18.78 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$85.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | None | $17.78 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$85.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | None | $18.07 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$85.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | None | $17.87 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$85.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | None | $18.48 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$85.00 |
$75* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | None | $18.03 |
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)
|
$98.40 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | None | $16.96 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$98.40 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | None | $15.21 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$98.40 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | None | $15.07 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$98.40 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | None | $15.68 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$98.40 |
$350 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$11.00 | $33.00 | None | $15.59 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$113.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$8.00 | $0.00 | None | $18.48 |
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 |
HAP Senior Plus Option 3 (PPO)
|
$118.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $25.00 | None | $18.78 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$122.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$1.00 | $3.00 | None | $16.95 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$122.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$1.00 | $3.00 | None | $15.05 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$122.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$1.00 | $3.00 | None | $15.18 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$122.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$1.00 | $3.00 | None | $15.96 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$122.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$1.00 | $3.00 | None | $15.81 |
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 |
Medicare Plus Blue PPO Signature (PPO)
|
$160.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $30.00 | None | $15.59 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$160.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $30.00 | None | $16.96 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$160.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $30.00 | None | $15.21 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$160.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $30.00 | None | $15.07 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$160.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $30.00 | None | $15.68 |
Browse Plan Formulary |
HAP Senior Plus Option 3 (HMO-POS)
|
$170.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $25.00 | None | $18.78 |
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 |
HAP Senior Plus Option 4 (PPO)
|
$190.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $25.00 | None | $18.78 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$197.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $0.00 | None | $18.03 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$197.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $0.00 | None | $17.78 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$197.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $0.00 | None | $18.07 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$197.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $0.00 | None | $17.87 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$197.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $0.00 | None | $18.48 |
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 |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$282.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$1.00 | $3.00 | None | $15.05 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$282.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$1.00 | $3.00 | None | $15.18 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$282.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$1.00 | $3.00 | None | $15.96 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$282.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$1.00 | $3.00 | None | $15.81 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$282.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$1.00 | $3.00 | None | $16.95 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$313.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | None | $15.21 |
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 |
Medicare Plus Blue PPO Assure (PPO)
|
$313.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | None | $15.68 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$313.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | None | $15.07 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$313.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | None | $15.59 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$313.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$7.00 | $21.00 | None | $16.96 |
Browse Plan Formulary |