AMOX-CLAV 200-28.5 MG/5 ML SUS (100 ML ) (NDC: 00781610246)
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 TX-0007 (PPO)
|
$0.00 |
$295* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$12.00 | $0.00 | None | $3.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC TX-0026 (HMO-POS)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$14.00 | $0.00 | None | $3.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC TX-0041 (HMO-POS)
|
$0.00 |
$300* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $0.00 | None | $3.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Choice Plan (PPO)
|
$0.00 |
$250* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$10.00 | $10.00 | None | $2.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Freedom Preferred Plan (PPO)
|
$0.00 |
$150* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$0.00 | $0.00 | None | $0.79 |
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 |
Blue Cross Medicare Advantage Complete (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $14.23 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Cross Medicare Advantage Dental Premier (PPO)
|
$0.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $13.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Cross Medicare Advantage Dental Value (HMO)
|
$0.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $13.15 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Cross Medicare Advantage Health Choice (PPO)
|
$0.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $13.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Cross Medicare Advantage Saver (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $13.48 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Cross Medicare Advantage Value (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$8.00 | $16.00 | None | $10.89 |
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 |
CHRISTUS Health Medicare Complete (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $0.00 | None | $12.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Medicare (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$4.00 | $0.00 | None | $18.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$4.00 | $0.00 | None | $17.48 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$4.00 | $0.00 | None | $18.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$4.00 | $0.00 | None | $17.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$4.00 | $0.00 | None | $11.11 |
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 |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$4.00 | $0.00 | None | $15.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$4.00 | $0.00 | None | $17.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Savings Medicare (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$4.00 | $0.00 | None | $12.39 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$4.00 | $0.00 | None | $18.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$4.00 | $0.00 | None | $17.48 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H0028-041 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $90.00 | None | $9.63 |
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 H5216-352 (PPO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $90.00 | None | $8.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-358 (PPO)
|
$0.00 |
$395 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $8.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$12.00 | $24.00 | None | $16.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Choice Care Select (HMO)
|
$0.00 |
$200 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $40.00 | None | $16.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Complete Care TX-001A (Regional PPO C-SNP)
|
$10.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $4.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna TotalCare (HMO D-SNP)
|
$13.50 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $24.37 |
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 Together in Health (PPO I-SNP)
|
$15.30 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $8.88 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete TX-V001 (HMO-POS D-SNP)
|
$16.90 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $3.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
CHRISTUS Health Medicare Plus (HMO)
|
$20.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $0.00 | None | $12.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Complement Assist (HMO)
|
$21.10 |
$505 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $94.00 | None | $7.65 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Cross Medicare Advantage Dual Care Plus (HMO D-SNP)
|
$21.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $12.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Harmony (HMO D-SNP)
|
$21.80 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $8.95 |
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 Complete Care TX-0029 (Regional PPO C-SNP)
|
$22.00 |
$295* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$12.00 | $0.00 | None | $4.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Liberty Nurture (HMO D-SNP)
|
$22.60 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $8.97 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Dual Complete Plan (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $9.91 |
Browse Plan Formulary all covered insulin pay $35 or less |
American Health Advantage of Texas (HMO I-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $15.95 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H0028-032 (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
$0.00 | $0.00 | None | $8.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Complete Care (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $16.28 |
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 |
Provider Partners Texas Advantage Plan (HMO I-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $16.27 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete TX-D002 (HMO-POS D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $3.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete TX-D002 (HMO-POS D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $4.07 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete TX-D002 (HMO-POS D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $4.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete TX-S001 (Regional PPO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $4.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete TX-S003 (HMO-POS D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $4.16 |
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 Dual Advantage (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | None | $16.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Dual Advantage (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | None | $16.29 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Dual Advantage (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | None | $18.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Dual Advantage (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | None | $15.70 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Dual Advantage (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
15% | 15% | None | $15.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
$0.00 | $0.00 | None | $15.70 |
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 Full Dual Advantage (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
$0.00 | $0.00 | None | $18.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
$0.00 | $0.00 | None | $16.98 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Full Dual Advantage (HMO D-SNP)
|
$28.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
$0.00 | $0.00 | None | $15.99 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-043 (PPO)
|
$32.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $8.49 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-043 (PPO)
|
$32.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $9.63 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-043 (PPO)
|
$32.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $8.19 |
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 Medicare Advantage TX-0030 (Regional PPO)
|
$48.00 |
$395* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$12.00 | $0.00 | None | $4.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R4182-004 (Regional PPO)
|
$49.00 |
$275 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $8.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-042 (PPO)
|
$65.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 3* |
Preferred Brand |
$47.00 | $131.00 | None | $8.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice R4182-003 (Regional PPO)
|
$72.00 |
$175 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $8.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
Blue Cross Medicare Advantage Flex (PPO)
|
$238.00 |
$545 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | None | $13.45 |
Browse Plan Formulary all covered insulin pay $35 or less |