AMOX TR-POTASSIUM CLAVULANATE 250-125MG TABLET [Augmentin] (30 BOT) (NDC: 00781187431)
2024 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 |
AARP Medicare Advantage from UHC WA-0002 (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$12.00 | $0.00 | None | $37.35 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC WA-0006 (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$12.00 | $0.00 | None | $35.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC WA-0007 (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $0.00 | None | $37.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite Plan (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $53.50 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Extra Value Plan (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $53.50 |
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 |
Aetna Medicare Preferred Plan (PPO)
|
$0.00 |
$150 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $51.89 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare SmartFit Plan (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
50% | 50% | None | $51.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (HMO-POS)
|
$0.00 |
$150 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $53.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Health Plan of WA MA Plan 1 (HMO)
|
$0.00 |
$230* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $20.00 | None | $119.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H2486-006 (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $64.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H5619-063 (HMO)
|
$0.00 |
$500* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$15.00 | $0.00 | None | $64.84 |
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 H5216-247 (PPO)
|
$0.00 |
$125* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$8.00 | $0.00 | None | $61.95 |
Browse Plan Formulary all covered insulin pay $35 or less |
Kaiser Permanente Medicare Advantage Key (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$7.00 | $0.00 | None | $111.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | $20.00 | None | $81.05 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | $20.00 | None | $79.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
Premera Blue Cross Medicare Advantage (HMO)
|
$0.00 |
$160 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $64.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
Providence Medicare Pine + Rx (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $99.36 |
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 |
Regence BlueAdvantage HMO (HMO)
|
$0.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$12.00 | $0.00 | None | $86.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence BlueAdvantage HMO (HMO)
|
$0.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$12.00 | $0.00 | None | $79.60 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence MedAdvantage + Rx Core (PPO)
|
$0.00 |
$375* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$13.00 | $0.00 | None | $85.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback (HMO)
|
$0.00 |
$440 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $25.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Mutual of Omaha No Premium Open (PPO)
|
$0.00 |
$100 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $24.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
|
$0.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $25.16 |
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 |
Wellpoint Kidney Care (HMO C-SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$42.00 | $126.00 | None | $127.77 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Assist (HMO)
|
$14.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $94.00 | None | $27.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$20.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $24.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Liberty (HMO D-SNP)
|
$24.90 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $24.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Mutual of Omaha Low Premium Open (PPO)
|
$29.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$42.00 | $84.00 | None | $24.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Dual Advantage (HMO D-SNP)
|
$29.20 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | None | $98.32 |
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 |
UHC Nursing Home Plan WA-F001 (PPO I-SNP)
|
$29.90 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $34.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$33.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $80.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Complete Care (HMO D-SNP)
|
$33.10 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $80.21 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Value Plus H5619-134 (HMO)
|
$34.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $60.46 |
Browse Plan Formulary all covered insulin pay $35 or less |
Kaiser Permanente Medicare Advantage Vital (HMO)
|
$34.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | $0.00 | None | $111.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H5619-136 (HMO D-SNP)
|
$35.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $60.18 |
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 |
Humana Gold Plus SNP-DE H5619-136 (HMO D-SNP)
|
$35.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $59.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H5619-136 (HMO D-SNP)
|
$35.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $64.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H5619-136 (HMO D-SNP)
|
$35.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $53.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Providence Medicare Cottonwood + Rx (HMO-POS)
|
$35.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $99.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence MedAdvantage + Rx Primary (PPO)
|
$35.00 |
$300* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$13.00 | $0.00 | None | $82.17 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence MedAdvantage + Rx Primary (PPO)
|
$35.00 |
$300* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$13.00 | $0.00 | None | $75.92 |
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 |
Regence MedAdvantage + Rx Primary (PPO)
|
$35.00 |
$300* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$13.00 | $0.00 | None | $85.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$36.10 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $24.96 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Health Plan of WA MA Plan 2 (HMO)
|
$38.40 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | $20.00 | None | $118.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC WA-0004 (PPO)
|
$39.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$12.00 | $0.00 | None | $37.35 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Choice Plan (PPO)
|
$39.00 |
$150 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $53.38 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Health Plan of WA Dual Complete (HMO D-SNP)
|
$40.60 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $119.30 |
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 |
Community Health Plan of WA Dual Select (HMO D-SNP)
|
$40.60 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $119.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H5619-155 (HMO D-SNP)
|
$40.60 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $58.20 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Care Advantage WA-E001 (PPO I-SNP)
|
$40.60 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$12.00 | $0.00 | None | $34.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete WA-D001 (PPO D-SNP)
|
$40.60 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $34.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete WA-D002 (HMO-POS D-SNP)
|
$40.60 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $34.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete WA-V001 (HMO-POS D-SNP)
|
$40.60 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $34.99 |
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 |
AARP Medicare Advantage from UHC WA-0005 (HMO-POS)
|
$42.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$12.00 | $0.00 | None | $34.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plus Plan (HMO-POS)
|
$43.00 |
$150 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $53.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence BlueAdvantage HMO Plus (HMO)
|
$46.00 |
$100* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$12.00 | $24.00 | None | $83.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Premera Blue Cross Medicare Advantage Classic (HMO)
|
$54.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $120.00 | None | $64.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H5619-059 (HMO)
|
$60.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$0.00 | $0.00 | None | $57.47 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Health Plan of WA MA Plan 3 (HMO)
|
$79.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | $20.00 | None | $119.08 |
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 |
Regence MedAdvantage + Rx Classic (PPO)
|
$82.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$13.00 | $26.00 | None | $81.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC WA-0010 (HMO-POS)
|
$84.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$12.00 | $0.00 | None | $34.73 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Select Plan (PPO)
|
$89.00 |
$150 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $300.00 | None | $52.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Kaiser Permanente Medicare Advantage Essential (HMO)
|
$94.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | $0.00 | None | $111.55 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-047 (PPO)
|
$100.00 |
$320* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $0.00 | None | $60.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence MedAdvantage + Rx Enhanced (PPO)
|
$147.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$8.00 | $16.00 | None | $81.04 |
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 |
Kaiser Permanente Medicare Advantage Optimal (HMO)
|
$327.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$5.00 | $0.00 | None | $111.55 |
Browse Plan Formulary all covered insulin pay $35 or less |