AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) (100 BOT) (NDC: 00603221321)
2013 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 |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | P | $2.66 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | P | $2.66 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | P | $2.66 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | P | $2.66 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | P | $2.66 |
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 |
HealthPlus MedicarePlus-AdvantageHMO-POS Option 0 (HMO-POS)
|
$0.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$6.00 | $12.00 | P | $3.47 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$12.50 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $2.66 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$12.50 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $2.66 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$12.50 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $2.66 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$12.50 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $2.66 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$12.50 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $2.66 |
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 R5826-072 (Regional PPO)
|
$20.80 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | P | $5.93 |
Browse Plan Formulary |
HealthPlus MedicarePlus-Advantage D-SNP (HMO SNP)
|
$23.60 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | P | $3.47 |
Browse Plan Formulary |
Erickson Advantage Guardian (HMO-POS SNP)
|
$28.30 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$4.00 | $8.00 | None | $3.74 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$32.70 |
$325* | No additional gap coverage, only the Donut Hole Discount | 1* |
Generic |
$0.00 | $0.00 | None | $1.83 |
Browse Plan Formulary |
Meridian Advantage Plan of Michigan (HMO SNP)
|
$34.10 |
$325 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
n/a | n/a | None | $6.94 |
Browse Plan Formulary |
CareSource Advantage (HMO SNP)
|
$34.20 |
$325* | No additional gap coverage, only the Donut Hole Discount | 1* |
Generic |
$0.00 | $0.00 | None | $2.21 |
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 (HMO SNP)
|
$34.20 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
n/a | n/a | None | $3.78 |
Browse Plan Formulary |
HumanaChoice R5826-006 (Regional PPO)
|
$37.50 |
$0 | Few Generics, Few Brands | 1 |
Preferred Generic |
$8.00 | $0.00 | P | $5.93 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$44.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$6.00 | $15.00 | P | $5.12 |
Browse Plan Formulary |
Erickson Advantage Freedom (HMO-POS)
|
$48.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$9.00 | $18.00 | None | $3.86 |
Browse Plan Formulary |
HAP Senior Plus - Henry Ford (HMO)
|
$54.00 |
$50 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$2.00 | $5.00 | P | $5.12 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$55.60 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$9.00 | $22.50 | None | $2.46 |
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 |
HealthPlus MedicarePlus-AdvantageHMO-POS Option 1 (HMO-POS)
|
$79.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$7.00 | $14.00 | P | $3.47 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$86.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $2.66 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$86.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $2.66 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$86.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $2.66 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$86.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $2.66 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$86.00 |
$325 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $2.66 |
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 |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$94.00 |
$25 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$2.00 | $5.00 | P | $5.12 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$97.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$10.00 | $25.00 | None | $2.46 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$97.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$10.00 | $25.00 | None | $2.46 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$97.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$10.00 | $25.00 | None | $2.46 |
Browse Plan Formulary |
Alliance Medicare PPO (PPO)
|
$103.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$2.00 | $5.00 | P | $5.12 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 | Many Generics | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | P | $2.66 |
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 |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 | Many Generics | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | P | $2.66 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 | Many Generics | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | P | $2.66 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 | Many Generics | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | P | $2.66 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$113.00 |
$0 | Many Generics | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | P | $2.66 |
Browse Plan Formulary |
HAP Senior Plus - Henry Ford (HMO)
|
$122.00 |
$50 | All Generics | 1 |
Preferred Generic |
$2.00 | $5.00 | P | $5.12 |
Browse Plan Formulary |
HealthPlus MedicarePlus-AdvantageHMO-POS Option 2 (HMO-POS)
|
$125.00 |
$0 | All Generics | 1 |
Generic |
$6.00 | $12.00 | P | $3.47 |
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 |
Medicare Plus Blue PPO Signature (PPO)
|
$125.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$15.00 | $37.50 | None | $2.66 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$125.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$15.00 | $37.50 | None | $2.66 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$125.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$15.00 | $37.50 | None | $2.66 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$125.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$15.00 | $37.50 | None | $2.66 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$125.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$15.00 | $37.50 | None | $2.66 |
Browse Plan Formulary |
HealthPlus MedicarePlus-AdvantagePPO Enhanced (PPO)
|
$136.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$6.00 | $12.00 | P | $3.47 |
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 |
PriorityMedicare (HMO-POS)
|
$136.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$8.00 | $20.00 | None | $2.46 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$154.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$8.00 | $20.00 | None | $2.46 |
Browse Plan Formulary |
HAP Senior Plus - Expanded Network (HMO-POS)
|
$169.00 |
$25 | All Generics | 1 |
Preferred Generic |
$2.00 | $5.00 | P | $5.12 |
Browse Plan Formulary |
Alliance Medicare PPO (PPO)
|
$174.00 |
$50 | All Generics | 1 |
Preferred Generic |
$4.00 | $10.00 | P | $5.12 |
Browse Plan Formulary |
Erickson Advantage Champion (HMO-POS SNP)
|
$176.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$4.00 | $8.00 | None | $3.86 |
Browse Plan Formulary |
Erickson Advantage Signature with Drugs (HMO-POS)
|
$176.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$7.00 | $14.00 | None | $3.86 |
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 |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$218.00 |
$0 | Many Generics | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | P | $2.66 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$218.00 |
$0 | Many Generics | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | P | $2.66 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$218.00 |
$0 | Many Generics | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | P | $2.66 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$218.00 |
$0 | Many Generics | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | P | $2.66 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$218.00 |
$0 | Many Generics | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | P | $2.66 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$244.00 |
$0 | Many Generics | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $2.66 |
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 |
Medicare Plus Blue PPO Assure (PPO)
|
$244.00 |
$0 | Many Generics | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $2.66 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$244.00 |
$0 | Many Generics | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $2.66 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$244.00 |
$0 | Many Generics | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $2.66 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$244.00 |
$0 | Many Generics | 2 |
Non-Preferred Generic |
$10.00 | $25.00 | None | $2.66 |
Browse Plan Formulary |