AMPICILLIN 125mg/1 10 VIAL, GLASS in 1 PACKAGE / 1 INJECTION, POWDER, FOR SOLUTION in 1 VIAL, GLASS (10 VIAL, GLASS in 1 PKG ) (NDC: 00781340095)
2024 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
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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 |
AARP Medicare Advantage from UHC MA-0003 (HMO-POS)
|
$0.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $41.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC MA-0006 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $41.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Discover Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | None | $41.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Explorer Plan (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $41.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $41.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 |
CCA Medicare Preferred (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $131.00 | None | $66.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
CCA One Care (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Tier 3 |
0% | 0% | None | $66.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Orange (HMO)
|
$0.00 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
6* |
Tier 6 |
$0.00 | n/a | None | $39.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Health New England Baystate Health Preferred (HMO)
|
$0.00 |
$270 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None | $39.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
Health New England Medicare Compass (PPO)
|
$0.00 |
$290 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None | $39.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
Health New England Medicare Value (HMO)
|
$0.00 |
$290 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None | $39.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
|
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 H5216-138 (PPO)
|
$0.00 |
$395 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $35.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-249 (PPO)
|
$0.00 |
$350 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $35.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue SaverRx (HMO)
|
$0.00 |
$300* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$8.00 | $16.00 | None | $35.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare PPO Blue SaverRx (PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $20.00 | None | $35.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred Access Rx (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $39.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Saver Rx (HMO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $39.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 |
Tufts Medicare Preferred HMO Smart Saver Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $39.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
UnitedHealthcare Connected(r) for One Care (Medicare-Medicaid Plan)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
1 |
Tier 1 |
0% | 0% | None | $41.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback Open (PPO)
|
$0.00 |
$545 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
47% | 47% | None | $30.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
|
$0.00 |
$400 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $30.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium Open (PPO)
|
$0.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
43% | 43% | None | $30.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Whole Health NHC (HMO D-SNP)
|
$16.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $37.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 |
CCA Medicare Value (PPO)
|
$20.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | None | $66.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Health Plan Senior Care Options (HMO D-SNP)
|
$24.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $39.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Health Plan Senior Care Options CW (HMO D-SNP)
|
$24.40 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $39.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Senior Care Options MA-Y001 (HMO D-SNP)
|
$26.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $41.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-250 (PPO)
|
$27.00 |
$295 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $35.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue ValueRx (HMO)
|
$28.00 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$6.00 | $12.00 | None | $35.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 HMO Blue ValueRx (HMO)
|
$28.00 |
$320* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$6.00 | $12.00 | None | $35.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plus (PPO)
|
$29.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
40% | 40% | None | $41.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Whole Health (HMO D-SNP)
|
$31.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $37.11 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Senior Care Options NHC MA-Y002 (HMO D-SNP)
|
$31.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
$0.00 | $0.00 | None | $41.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$40.00 |
$225 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $39.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$40.00 |
$225 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $39.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 |
Tufts Medicare Preferred HMO Basic Rx (HMO)
|
$40.00 |
$225 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $39.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
CCA Senior Care Options (HMO D-SNP)
|
$43.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
25% | 25% | None | $66.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Longevity Health Plan (HMO I-SNP)
|
$43.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $30.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
WellSense Senior Care Options (HMO D-SNP)
|
$43.50 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | P | $30.19 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC MA-0004 (HMO-POS)
|
$45.00 |
$175 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $41.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC NG-0001 (Regional PPO)
|
$58.00 |
$395 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $41.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 |
Fallon Medicare Plus Super Saver (HMO)
|
$60.00 |
$545* |
No additional gap coverage, only the Donut Hole Discount |
6* |
Tier 6 |
$0.00 | n/a | None | $39.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Green (HMO)
|
$66.00 |
$175* |
No additional gap coverage, only the Donut Hole Discount |
6* |
Tier 6 |
$0.00 | n/a | None | $39.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Green (HMO)
|
$66.00 |
$175* |
No additional gap coverage, only the Donut Hole Discount |
6* |
Tier 6 |
$0.00 | n/a | None | $39.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Green (HMO)
|
$66.00 |
$175* |
No additional gap coverage, only the Donut Hole Discount |
6* |
Tier 6 |
$0.00 | n/a | None | $39.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare PPO Blue ValueRx (PPO)
|
$72.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$6.00 | $12.00 | None | $35.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare PPO Blue ValueRx (PPO)
|
$72.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$6.00 | $12.00 | None | $35.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 |
Wellcare Premium Enhanced Open (PPO)
|
$75.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $30.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue FlexRx (HMO-POS)
|
$78.00 |
$260* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$5.00 | $10.00 | None | $35.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare HMO Blue FlexRx (HMO-POS)
|
$78.00 |
$260* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$5.00 | $10.00 | None | $35.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$89.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $39.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$89.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $39.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Value Rx (HMO)
|
$89.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $39.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 |
Health New England Medicare Compass Premier (PPO)
|
$99.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None | $39.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$109.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $39.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$109.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $39.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx (HMO)
|
$109.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $39.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Blue (HMO)
|
$110.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
6 |
Tier 6 |
$0.00 | n/a | None | $39.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Fallon Medicare Plus Blue (HMO)
|
$110.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
6 |
Tier 6 |
$0.00 | n/a | None | $39.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 |
Fallon Medicare Plus Blue (HMO)
|
$110.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
6 |
Tier 6 |
$0.00 | n/a | None | $39.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Health New England Medicare Plus (HMO)
|
$113.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None | $39.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$129.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$80.00 | $240.00 | None | $39.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$129.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$80.00 | $240.00 | None | $39.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Tufts Medicare Preferred HMO Prime Rx Plus (HMO)
|
$129.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$80.00 | $240.00 | None | $39.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Health New England Medicare Premium (HMO)
|
$168.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $270.00 | None | $39.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 HMO Blue PlusRx (HMO)
|
$220.00 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$5.00 | $10.00 | None | $35.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Medicare PPO Blue PlusRx (PPO)
|
$238.00 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$5.00 | $10.00 | None | $35.86 |
Browse Plan Formulary all covered insulin pay $35 or less |