METRONIDAZOLE TABLETS USP 250MG 250 BOTPL (250 BOTPL) (NDC: 50111033306)
2013 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
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 |
Amerivantage Balance + Rx (HMO)
|
$0.00 |
$0 | Some Generics | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $29.50 |
Browse Plan Formulary |
Amerivantage Classic Choice + Rx Plan (HMO-POS)
|
$0.00 |
$0 | Some Generics | 1 |
Preferred Generic |
$3.00 | $6.00 | None | $29.50 |
Browse Plan Formulary |
Elderplan Classic: Zero Premium (HMO)
|
$0.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$4.00 | $10.00 | None | $29.78 |
Browse Plan Formulary |
Healthfirst 65 Plus Plan (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$0.00 | $0.00 | None | $27.24 |
Browse Plan Formulary |
Healthfirst Jade Benefits Plan (HMO)
|
$0.00 |
$0 | Many Generics, Few Brands | 1 |
Generic |
$0.00 | $0.00 | None | $27.24 |
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 |
Liberty Health Advantage Preferred Choice (HMO)
|
$0.00 |
$0 | All Generics | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $30.67 |
Browse Plan Formulary |
UnitedHealthcare MedicareComplete Choice (Regional PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $125.00 | None | $26.37 |
Browse Plan Formulary |
VIP Essential (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$5.00 | $10.00 | None | $29.62 |
Browse Plan Formulary |
VIP Essential (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$5.00 | $10.00 | None | $29.62 |
Browse Plan Formulary |
VIP Essential (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$5.00 | $10.00 | None | $29.62 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Enhanced (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$1.00 | $2.50 | None | $28.55 |
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 |
WellCare Choice (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$0.00 | $0.00 | None | $30.88 |
Browse Plan Formulary |
WellCare Rx (HMO)
|
$1.60 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$8.00 | $0.00 | None | $30.88 |
Browse Plan Formulary |
WellCare Liberty (HMO SNP)
|
$20.60 |
$325* | No additional gap coverage, only the Donut Hole Discount | 1* |
Generic |
$0.00 | $0.00 | None | $30.82 |
Browse Plan Formulary |
Empire MediBlue Plus (HMO)
|
$30.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 2* |
Non-Preferred Generic |
$12.00 | $18.00 | None | $33.03 |
Browse Plan Formulary |
Healthfirst Increased Benefits Plan (HMO)
|
$35.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $27.24 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$35.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $26.52 |
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 |
Empire MediBlue Freedom I (PPO)
|
$38.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 2* |
Non-Preferred Generic |
$14.00 | $21.00 | None | $33.03 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Preferred (HMO SNP)
|
$40.10 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $28.55 |
Browse Plan Formulary |
Elderplan Advantage For Nursing Home Residents (HMO SNP)
|
$40.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $29.78 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$40.40 |
$325* | No additional gap coverage, only the Donut Hole Discount | 1* |
Generic |
$0.00 | $0.00 | None | $30.88 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO SNP)
|
$41.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
n/a | n/a | None | $26.46 |
Browse Plan Formulary |
GuildNet Health Advantage (HMO-POS SNP)
|
$41.60 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $29.62 |
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 |
Healthfirst AssuredCare (HMO SNP)
|
$43.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $27.24 |
Browse Plan Formulary |
Healthfirst CompleteCare (HMO SNP)
|
$43.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
n/a | n/a | None | $27.24 |
Browse Plan Formulary |
Healthfirst Life Improvement Plan (HMO SNP)
|
$43.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $27.24 |
Browse Plan Formulary |
Healthfirst Maximum Plan (HMO SNP)
|
$43.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
n/a | n/a | None | $27.24 |
Browse Plan Formulary |
Amerivantage Specialty + Rx (HMO SNP)
|
$43.20 |
$325* | Many Generics, Few Brands | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $29.50 |
Browse Plan Formulary |
CenterLight Direct Complete Plan (HMO SNP)
|
$43.20 |
$325* | No additional gap coverage, only the Donut Hole Discount | 1* |
Generic |
$7.25 | $21.75 | None | $33.93 |
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 |
CenterLight Direct Total Plan (HMO SNP)
|
$43.20 |
$185* | No additional gap coverage, only the Donut Hole Discount | 1* |
Generic |
$8.00 | $24.00 | None | $33.93 |
Browse Plan Formulary |
Dual Eligible (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$4.00 | $8.00 | None | $29.62 |
Browse Plan Formulary |
Dual Eligible (PPO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$4.00 | $8.00 | None | $29.62 |
Browse Plan Formulary |
Elderplan Extra Help (HMO)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $29.78 |
Browse Plan Formulary |
Elderplan For Medicaid Beneficiaries (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $29.78 |
Browse Plan Formulary |
Elderplan Medicaid Advantage (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $29.78 |
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 |
Elderplan Plus Long Term Care (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $29.78 |
Browse Plan Formulary |
Fidelis Dual Advantage Flex (HMO SNP)
|
$43.20 |
$320* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $27.74 |
Browse Plan Formulary |
Fidelis Long Term Care Advantage (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $27.74 |
Browse Plan Formulary |
Fidelis Medicare Advantage Flex (HMO-POS)
|
$43.20 |
$320* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $27.74 |
Browse Plan Formulary |
GuildNet Gold (HMO-POS SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
n/a | n/a | None | $29.62 |
Browse Plan Formulary |
Liberty Health Advantage Dual Power (HMO SNP)
|
$43.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $31.48 |
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 |
Empire MediBlue Select (HMO)
|
$44.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$10.00 | $15.00 | None | $33.03 |
Browse Plan Formulary |
VIP (HMO)
|
$44.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$5.00 | $10.00 | None | $29.62 |
Browse Plan Formulary |
VIP (HMO)
|
$44.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$5.00 | $10.00 | None | $29.62 |
Browse Plan Formulary |
VIP (HMO)
|
$44.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$5.00 | $10.00 | None | $29.62 |
Browse Plan Formulary |
PPO II (PPO)
|
$52.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$5.00 | $10.00 | None | $29.62 |
Browse Plan Formulary |
VNSNY CHOICE Medicare Maximum (HMO SNP)
|
$78.50 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
n/a | n/a | None | $28.55 |
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 |
VNSNY CHOICE Total (HMO SNP)
|
$95.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
n/a | n/a | None | $28.55 |
Browse Plan Formulary |
PPO III (PPO)
|
$112.50 |
$0 | All Generics | 1 |
Preferred Generic |
$5.00 | $10.00 | None | $29.62 |
Browse Plan Formulary |
PPO High Option (PPO)
|
$218.50 |
$0 | All Generics | 1 |
Preferred Generic |
$5.00 | $10.00 | None | $29.62 |
Browse Plan Formulary |
VIP High Option (HMO)
|
$218.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$5.00 | $10.00 | None | $29.62 |
Browse Plan Formulary |
VIP High Option (HMO)
|
$218.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$5.00 | $10.00 | None | $29.62 |
Browse Plan Formulary |
VIP High Option (HMO)
|
$218.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$5.00 | $10.00 | None | $29.62 |
Browse Plan Formulary |