{4 (amoxicillin 500 MG Oral Capsule) / 2 (clarithromycin 500 MG Oral Tablet) / 2 (lansoprazole 30 MG Delayed Release Oral Capsule) } Pack
amoxicillin
RxCUI: 757968
What the CMS Formulary Data Shows for {4 (amoxicillin 500 MG Oral Capsule) / 2 (clarithromycin 500 MG Oral Tablet) / 2 (lansoprazole 30 MG Delayed Release Oral Capsule) } Pack
Per the CMS 2026 Part D formulary file, {4 (amoxicillin 500 MG Oral Capsule) / 2 (clarithromycin 500 MG Oral Tablet) / 2 (lansoprazole 30 MG Delayed Release Oral Capsule) } Pack (RxNorm concept RXCUI 757968, generic name amoxicillin) appears on 58 distinct formulary files spanning 245 Medicare Part D plan offerings - 4.8% of enrollable Part D products, selective placement; verify formulary inclusion before enrolling. Tier placement ranges from Tier 1 to Tier 4, with a cross-plan average of Tier 2.4.
Real-world access to {4 (amoxicillin 500 MG Oral Capsule) / 2 (clarithromycin 500 MG Oral Tablet) / 2 (lansoprazole 30 MG Delayed Release Oral Capsule) } Pack depends on utilization management as much as tier placement: 0% of covering formularies require prior authorization. 0% require step therapy. 8.6% apply quantity limits.
Medicare Part D spending dashboard figures are not published for this drug. The plan-by-plan detail below lists exactly which PDP and MA-PD contracts carry {4 (amoxicillin 500 MG Oral Capsule) / 2 (clarithromycin 500 MG Oral Tablet) / 2 (lansoprazole 30 MG Delayed Release Oral Capsule) } Pack today.
Coverage Details
- Formularies covering
- 58
- Plans covering
- 245
- Coverage rate
- 4.8%
- Tier range
- Tier 1 – Tier 4
- Average tier
- Tier 2, Generic
Restrictions
- Prior authorization required
- 0% of formularies
- Step therapy required
- 0% of formularies
- Quantity limits
- 8.6% of formularies
Tier Distribution Across Plans
Medicare Advantage Plans (MA-PD) Covering {4 (amoxicillin 500 MG Oral Capsule) / 2 (clarithromycin 500 MG Oral Tablet) / 2 (lansoprazole 30 MG Delayed Release Oral Capsule) } Pack
100 Medicare Advantage plans with Part D drug coverage include this drug.
| Plan | Insurer | Tier | PA | Premium | States |
|---|---|---|---|---|---|
| PHP (HMO C-SNP) | AIDS HEALTHCARE FOUNDATION | T1 | No | $0 | CA |
| Elevate Medicare Choice (HMO D-SNP) | DENVER HEALTH MEDICAL PLAN, INC. | T1 | No | $0 | CO |
| AllCare Advantage Redwood Rx (HMO D-SNP) | ALLCARE HEALTH PLAN, INC. | T1 | No | $0 | OR |
| PrimeWest Senior Health Complete (HMO D-SNP) | PRIMEWEST RURAL MN HEALTH CARE ACCESS INITIATIVE | T1 | No | $0 | MN |
| Prime Health Complete (HMO D-SNP) | PRIMEWEST RURAL MN HEALTH CARE ACCESS INITIATIVE | T1 | No | $0 | MN |
| DualConnect (HMO D-SNP) | SANTA CLARA COUNTY HEALTH AUTHORITY | T1 | No | $0 | CA |
| VNS Health Total (HMO D-SNP) | VNS CHOICE | T1 | No | $0 | NY |
| Alterwood Advantage Dual Secure (HMO D-SNP) | ALTERWOOD ADVANTAGE, INC. | T1 | No | $0 | MD |
| Nascentia Dual Advantage (HMO D-SNP) | VISITING NURSE ASSOCIATION OF CENTRAL NEW YORK | T1 | No | $0 | NY |
| Abilis Health Community (HMO I-SNP) | SIGNATURE ADVANTAGE, LLC | T1 | No | $0 | KY, TN |
| Arkansas Integrated Providers (AIP) Dual Advantage (HMO D-SNP) | ARKANSAS SUPERIOR SELECT, INC. | T1 | No | $0 | AR |
| CalOptima Health OneCare Complete (HMO D-SNP) | ORANGE COUNTY HEALTH AUTHORITY | T1 | No | $0 | CA |
| Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) | GATEWAY HEALTH PLAN, INC. | T1 | No | $0 | PA |
| Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) | GATEWAY HEALTH PLAN, INC. | T1 | No | $0 | PA |
| Highmark Health Options Duals (HMO D-SNP) | HIGHMARK HEALTH OPTIONS WEST VIRGINIA INC. | T1 | No | $0 | WV |
| Highmark Health Options Duals (HMO D-SNP) | HIGHMARK BCBSD, INC. | T1 | No | $0 | DE |
| Leon MediExtra (HMO) | LEON HEALTH, INC. | T1 | No | $0 | FL |
| Leon MediDual (HMO D-SNP) | LEON HEALTH, INC. | T1 | No | $0 | FL |
| Leon MediMore (HMO) | LEON HEALTH, INC. | T1 | No | $0 | FL |
| Leon MediMax (HMO D-SNP) | LEON HEALTH, INC. | T1 | No | $0 | FL |
| Gold Dialysis & Kidney Complete (HMO-POS C-SNP) | GOLD KIDNEY OF FLORIDA INC | T1 | No | $4.80 | FL |
| Texas Independence Health Plan, Inc. (HMO I-SNP) | TEXAS INDEPENDENCE HEALTH PLAN, INC. | T1 | No | $4.80 | TX |
| Texas Independence Community Plan (HMO I-SNP) | TEXAS INDEPENDENCE HEALTH PLAN, INC. | T1 | No | $4.80 | TX |
| Tribute Select (HMO-POS I-SNP) | ARKANSAS SUPERIOR SELECT, INC. | T1 | No | $8.90 | AR |
| ATRIO Special Needs Plan (HMO D-SNP) | ATRIO HEALTH PLANS | T1 | No | $10.50 | OR |
| ATRIO Special Needs Plan (HMO D-SNP) | ATRIO HEALTH PLANS | T1 | No | $10.50 | OR |
| Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) | GATEWAY HEALTH PLAN, INC. | T1 | No | $13.10 | PA |
| Gold Dialysis & Kidney Complete (HMO-POS C-SNP) | GOLD KIDNEY OF ARIZONA | T1 | No | $17.00 | AZ |
| Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) | GATEWAY HEALTH PLAN, INC. | T1 | No | $17.60 | PA |
| Alterwood Advantage Dual Value (HMO D-SNP) | ALTERWOOD ADVANTAGE, INC. | T1 | No | $31.20 | MD |
| Highmark Health Options Duals Select (HMO D-SNP) | HIGHMARK BCBSD, INC. | T1 | No | $31.20 | DE |
| Valor Health Plan (HMO I-SNP) | TSG GUARD, INC. | T1 | No | $31.40 | OH |
| WV Senior Advantage (HMO I-SNP) | WEST VIRGINIA SENIOR ADVANTAGE, INC. | T1 | No | $32.70 | WV |
| Abilis Health (HMO I-SNP) | SIGNATURE ADVANTAGE, LLC | T1 | No | $35.90 | KY, TN |
| CommuniCare Advantage ISNP (HMO I-SNP) | OH CHS SNP INC. | T1 | No | $38.40 | IN, MD, OH |
| VNS Health EasyCare Plus (HMO D-SNP) | VNS CHOICE | T1 | No | $51.60 | NY |
| Nascentia Skilled Nursing Facility (HMO I-SNP) | VISITING NURSE ASSOCIATION OF CENTRAL NEW YORK | T1 | No | $58.80 | NY |
| HealthSun HealthAdvantage Plan (HMO) | HEALTHSUN HEALTH PLANS, INC. | T2 | No | $0 | FL |
| HealthSun MediMax (HMO) | HEALTHSUN HEALTH PLANS, INC. | T2 | No | $0 | FL |
| HealthSun HealthAdvantage Plan (HMO) | HEALTHSUN HEALTH PLANS, INC. | T2 | No | $0 | FL |
| HealthSun HealthAdvantage Plan (HMO) | HEALTHSUN HEALTH PLANS, INC. | T2 | No | $0 | FL |
| HealthSun MediSun Plus (HMO D-SNP) | HEALTHSUN HEALTH PLANS, INC. | T2 | No | $0 | FL |
| HealthSun HealthAdvantage Plus (HMO) | HEALTHSUN HEALTH PLANS, INC. | T2 | No | $0 | FL |
| HealthSun HealthAdvantage Plus (HMO) | HEALTHSUN HEALTH PLANS, INC. | T2 | No | $0 | FL |
| HealthSun MediSun Extra (HMO D-SNP) | HEALTHSUN HEALTH PLANS, INC. | T2 | No | $0 | FL |
| HealthSun HealthAdvantage Plus (HMO) | HEALTHSUN HEALTH PLANS, INC. | T2 | No | $0 | FL |
| HealthSun VitalCare (HMO C-SNP) | HEALTHSUN HEALTH PLANS, INC. | T2 | No | $0 | FL |
| HealthSun VitalCare (HMO C-SNP) | HEALTHSUN HEALTH PLANS, INC. | T2 | No | $0 | FL |
| HealthSun MediSun Full Dual Plus (HMO D-SNP) | HEALTHSUN HEALTH PLANS, INC. | T2 | No | $0 | FL |
| HealthSun MediSun Full Dual Extra (HMO D-SNP) | HEALTHSUN HEALTH PLANS, INC. | T2 | No | $0 | FL |
Frequently Asked Questions
Is {4 (amoxicillin 500 MG Oral Capsule) / 2 (clarithromycin 500 MG Oral Tablet) / 2 (lansoprazole 30 MG Delayed Release Oral Capsule) } Pack covered by Medicare Part D?
Yes, {4 (amoxicillin 500 MG Oral Capsule) / 2 (clarithromycin 500 MG Oral Tablet) / 2 (lansoprazole 30 MG Delayed Release Oral Capsule) } Pack is covered by 245 Medicare Part D plans (4.8% of all Part D formularies).
What tier is {4 (amoxicillin 500 MG Oral Capsule) / 2 (clarithromycin 500 MG Oral Tablet) / 2 (lansoprazole 30 MG Delayed Release Oral Capsule) } Pack on Medicare Part D plans?
{4 (amoxicillin 500 MG Oral Capsule) / 2 (clarithromycin 500 MG Oral Tablet) / 2 (lansoprazole 30 MG Delayed Release Oral Capsule) } Pack averages Tier 2.4 across Part D plans, ranging from Tier 1 to Tier 4.
Does {4 (amoxicillin 500 MG Oral Capsule) / 2 (clarithromycin 500 MG Oral Tablet) / 2 (lansoprazole 30 MG Delayed Release Oral Capsule) } Pack require prior authorization?
0% of Part D formularies require prior authorization for {4 (amoxicillin 500 MG Oral Capsule) / 2 (clarithromycin 500 MG Oral Tablet) / 2 (lansoprazole 30 MG Delayed Release Oral Capsule) } Pack. Step therapy: 0%. Quantity limits: 8.6%.
Read our methodology - how this data is sourced, computed, and verified.