Metronidazole 500mg/100mL 24 BAG per CARTON / 100 mL in 1 BAG (24 BAG in 1 CARTON / 100 ) (NDC: 36000000124)
2015 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 |
AARP MedicareComplete (HMO)
|
$0.00 |
$220 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $36.54 |
Browse Plan Formulary |
AARP MedicareComplete Choice Plan 2 (Regional PPO)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $44.46 |
Browse Plan Formulary |
Amerivantage Classic + Rx (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$90.00 | $270.00 | None | $92.11 |
Browse Plan Formulary |
Amerivantage Specialty + Rx (HMO SNP)
|
$0.00 |
$320 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
$70.00 | $210.00 | None | $92.11 |
Browse Plan Formulary |
BlueMedicare HMO LifeTime (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | None | $51.48 |
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 |
BlueMedicare HMO MyTime (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | None | $68.76 |
Browse Plan Formulary |
CareDirect (HMO SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
4 |
Non-Preferred Brand |
$85.00 | $245.00 | None | $120.47 |
Browse Plan Formulary |
CareFree (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
4 |
Non-Preferred Brand |
$60.00 | $170.00 | None | $120.47 |
Browse Plan Formulary |
CareOne (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
4 |
Non-Preferred Brand |
$85.00 | $245.00 | None | $120.47 |
Browse Plan Formulary |
CareOne PLUS (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
4 |
Non-Preferred Brand |
$60.00 | $170.00 | None | $120.47 |
Browse Plan Formulary |
Freedom Medicare Plan Rx (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Brand |
$85.00 | $170.00 | None | $87.04 |
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 VIP Care (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Brand |
$75.00 | $150.00 | None | $84.40 |
Browse Plan Formulary |
Freedom VIP Savings (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None | $84.40 |
Browse Plan Formulary |
Freedom VIP Savings COPD (HMO SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None | $84.40 |
Browse Plan Formulary |
Humana Gold Plus - Diabetes (HMO SNP)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
4 |
Non-Preferred Brand |
$60.00 | $170.00 | None | $120.47 |
Browse Plan Formulary |
Humana Gold Plus H1036-040 (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
4 |
Non-Preferred Brand |
$55.00 | $155.00 | None | $113.27 |
Browse Plan Formulary |
Humana Gold Plus H1036-141 (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $120.47 |
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 R5826-074 (Regional PPO)
|
$0.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $113.51 |
Browse Plan Formulary |
Optimum Diamond Rewards (HMO-POS SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Brand |
$60.00 | $120.00 | None | $86.08 |
Browse Plan Formulary |
Optimum Diamond Rewards COPD (HMO-POS SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | None | $86.08 |
Browse Plan Formulary |
Optimum Gold Rewards Plan (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$80.00 | $160.00 | None | $88.00 |
Browse Plan Formulary |
Optimum Platinum Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Non-Preferred Brand |
$69.00 | $138.00 | None | $88.00 |
Browse Plan Formulary |
Preferred Secure Option (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $37.02 |
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 |
Ultimate Elite (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Preferred Brand |
$20.00 | $40.00 | P | $84.48 |
Browse Plan Formulary |
Ultimate Elite Plus (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Preferred Brand |
$10.00 | $20.00 | P | $84.48 |
Browse Plan Formulary |
WellCare Dividend (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $92.76 |
Browse Plan Formulary |
WellCare Essential (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $92.04 |
Browse Plan Formulary |
WellCare Value (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $93.24 |
Browse Plan Formulary |
Coventry Summit Maximum (HMO SNP)
|
$9.70 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
50% | 50% | None | $38.87 |
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 |
Humana Gold Plus SNP-DE H1036-102 (HMO SNP)
|
$15.20 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $120.47 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$17.70 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $100.00 | None | $92.76 |
Browse Plan Formulary |
CareNeeds (HMO SNP)
|
$17.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $120.47 |
Browse Plan Formulary |
WellCare Liberty (HMO SNP)
|
$18.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $100.00 | None | $92.76 |
Browse Plan Formulary |
WellCare Select (HMO SNP)
|
$19.90 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $100.00 | None | $92.52 |
Browse Plan Formulary |
BlueMedicare Regional PPO (Regional PPO)
|
$20.20 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$28.00 | $84.00 | None | $56.04 |
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 |
UnitedHealthcare Dual Complete LP (HMO SNP)
|
$24.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $36.54 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$24.30 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $45.90 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$24.80 |
$320* |
Yes, but No Gap Coverage for this drug. |
1* |
Generic |
$0.00 | $0.00 | None | $82.87 |
Browse Plan Formulary |
Freedom Medi-Medi Full (HMO SNP)
|
$25.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $86.80 |
Browse Plan Formulary |
Freedom Medi-Medi Partial (HMO SNP)
|
$25.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $86.80 |
Browse Plan Formulary |
Optimum Emerald Full (HMO SNP)
|
$25.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None | $86.56 |
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 |
Optimum Emerald Partial (HMO SNP)
|
$25.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$95.00 | $285.00 | None | $86.56 |
Browse Plan Formulary |
Sunshine Health Advantage (HMO SNP)
|
$25.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Injectable Drugs |
$95.00 | $95.00 | None | $82.36 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP (Regional PPO SNP)
|
$25.80 |
$320 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $44.46 |
Browse Plan Formulary |
AARP MedicareComplete Choice (PPO)
|
$29.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $36.54 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$35.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
50% | 50% | None | $49.45 |
Browse Plan Formulary |
HumanaChoice R5826-005 (Regional PPO)
|
$39.40 |
$100 |
Yes, this drug has Gap Coverage. |
4 |
Non-Preferred Brand |
$85.00 | $245.00 | None | $113.51 |
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 |
Humana Gold Choice H8145-061 (PFFS)
|
$101.00 |
$0 |
Yes, this drug has Gap Coverage. |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | None | $113.27 |
Browse Plan Formulary |
BlueMedicare PPO (PPO)
|
$127.10 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | None | $53.40 |
Browse Plan Formulary |
Aetna Medicare Select Plus Plan (HMO)
|
$139.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
50% | 50% | None | $48.49 |
Browse Plan Formulary |
Aetna Medicare Select Plus Plan (PPO)
|
$139.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Brand |
50% | 50% | None | $59.29 |
Browse Plan Formulary |