AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION [Amoxil] (100 mls ) (NDC: 00143988701)
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 VA-0005 (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $9.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC VA-0011 (HMO-POS)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $8.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC VA-0011 (HMO-POS)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $9.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC VA-0013 (HMO-POS)
|
$0.00 |
$350* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $8.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC VA-0017 (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $9.14 |
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 Premier Plan (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$10.00 | $10.00 | None | $3.66 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Select Plan (HMO-POS)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $0.00 | None | $3.36 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare SmartFit (HMO-POS)
|
$0.00 |
$250* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$10.00 | $10.00 | None | $3.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Grocery (HMO)
|
$0.00 |
$150* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $14.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Grocery (PPO)
|
$0.00 |
$95* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $14.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem I Carelon Chronic Care (HMO C-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $0.00 | None | $14.72 |
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 |
Anthem I Carelon Home Care (HMO I-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $0.00 | None | $14.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem I Carelon Lung Care (HMO C-SNP)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $0.00 | None | $14.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem I Carelon Medicare Advantage (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$5.00 | $0.00 | None | $14.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem I Carelon Premium Savings (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$12.50 | $0.00 | None | $14.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Kidney Care (HMO C-SNP)
|
$0.00 |
$325* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$4.00 | $0.00 | None | $14.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Medicare Advantage (PPO)
|
$0.00 |
$95* | Yes, but No Gap Coverage for this drug. | 1* |
Preferred Generic |
$4.00 | $0.00 | None | $14.72 |
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 Medicare (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $12.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Medicare (PPO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $12.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clear Spring Health Essential (HMO C-SNP)
|
$0.00 |
$250* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $8.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clear Spring Health Essential (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $8.64 |
Browse Plan Formulary all covered insulin pay $35 or less |
Clear Spring Health Essential (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $8.74 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Choice H8145-004 (PFFS)
|
$0.00 |
$160* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$5.00 | $0.00 | None | $9.18 |
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 - Diabetes and Heart (HMO C-SNP)
|
$0.00 |
$145* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $9.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$0.00 |
$150* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $9.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H5619-157 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $9.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H6622-004 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $9.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H6622-083 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $9.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-266 (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $9.14 |
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 H5216-308 (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $9.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-312 (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $9.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
LifeWorks Premier Care (HMO-POS I-SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$2.00 | n/a | None | $18.84 |
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 | 1 |
Preferred Generic |
$3.00 | $6.00 | None | $8.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Sentara Medicare Value (HMO)
|
$0.00 |
$150* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | $0.00 | None | $11.80 |
Browse Plan Formulary all covered insulin pay $35 or less |
Sentara Community Complete Select (HMO D-SNP)
|
$14.90 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $11.76 |
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 |
Sentara Community Complete (HMO D-SNP)
|
$17.10 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $11.76 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Together in Health (PPO I-SNP)
|
$18.30 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $9.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$21.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$10.00 | $0.00 | None | $9.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna Preferred Plus Medicare (HMO)
|
$23.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $12.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Cigna True Choice Plus Medicare (PPO)
|
$23.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $12.92 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Extra Help (HMO)
|
$25.10 |
$545* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $14.72 |
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 VA-0012 (HMO-POS)
|
$29.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $8.90 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC VA-0012 (HMO-POS)
|
$29.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $9.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Dual Advantage (HMO D-SNP)
|
$29.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $14.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$30.70 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $8.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Assure Value (HMO D-SNP)
|
$33.60 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $9.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Nursing Home Plan EX-F004 (PPO I-SNP)
|
$35.50 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $9.92 |
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 |
Molina Medicare Complete Care (HMO D-SNP)
|
$36.10 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $8.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Better Health of Virginia (HMO D-SNP)
|
$38.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $9.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Assure Premier (HMO D-SNP)
|
$38.40 |
$545 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | None | $9.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Dual Advantage (PPO D-SNP)
|
$38.50 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $14.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Full Dual Advantage (HMO D-SNP)
|
$38.50 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $14.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
Anthem Full Dual Advantage 2 (HMO D-SNP)
|
$38.50 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $14.72 |
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 |
Anthem Full Dual Advantage Support (HMO D-SNP)
|
$38.50 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $14.72 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H6622-085 (HMO)
|
$38.50 |
$545* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $9.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-363 (PPO)
|
$38.50 |
$545* | Yes, this drug has Gap Coverage. | 1* |
Preferred Generic |
$0.00 | $0.00 | None | $9.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Senior Care (HMO I-SNP)
|
$38.50 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | n/a | None | $18.84 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete VA-Q001 (HMO-POS D-SNP)
|
$38.50 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $9.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete VA-S001 (PPO D-SNP)
|
$38.50 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $9.04 |
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 |
UHC Dual Complete VA-S002 (HMO-POS D-SNP)
|
$38.50 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $9.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete VA-V001 (HMO-POS D-SNP)
|
$38.50 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $9.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete VA-Y001 (HMO-POS D-SNP)
|
$38.50 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $9.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete VA-Y002 (HMO-POS D-SNP)
|
$38.50 |
$545 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $9.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-144 (PPO)
|
$39.00 |
$265* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$4.00 | $0.00 | None | $9.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Choice Plan (PPO)
|
$88.00 |
$300* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$5.00 | $0.00 | None | $3.10 |
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 R1390-002 (Regional PPO)
|
$105.00 |
$480* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$8.00 | $0.00 | None | $9.32 |
Browse Plan Formulary all covered insulin pay $35 or less |