AMITRIP/PERPHEN 25-4 TABLET (500 BOT) (NDC: 00378057405)
2014 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 |
AARP MedicareComplete (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$8.00 | $16.00 | None | $100.02 |
Browse Plan Formulary |
AARP MedicareComplete Choice (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$8.00 | $16.00 | None | $100.12 |
Browse Plan Formulary |
AARP MedicareComplete Choice Plan 2 (Regional PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$8.00 | $16.00 | None | $98.94 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$0.00 |
$0 | Few Generics | 1 |
Generic |
$7.00 | $14.00 | None | $97.83 |
Browse Plan Formulary |
CareDirect (HMO SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 3 |
Preferred Brand |
$10.00 | $20.00 | P | $129.99 |
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 |
CareFree (HMO)
|
$0.00 |
$0 | Few Generics, Few Brands | 3 |
Preferred Brand |
$30.00 | $80.00 | P | $129.99 |
Browse Plan Formulary |
CareOne (HMO)
|
$0.00 |
$0 | Some Generics, Few Brands | 3 |
Preferred Brand |
$25.00 | $65.00 | P | $129.99 |
Browse Plan Formulary |
CareOne PLUS (HMO)
|
$0.00 |
$0 | Some Generics, Few Brands | 3 |
Preferred Brand |
$10.00 | $20.00 | P | $129.99 |
Browse Plan Formulary |
Coventry Summit Plus (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$75.00 | $225.00 | None | $81.23 |
Browse Plan Formulary |
Day Break (HMO)
|
$0.00 |
$0 | All Generics | 1 |
Generic |
$0.00 | $0.00 | None | $18.85 |
Browse Plan Formulary |
Freedom Medicare Plan Rx (HMO)
|
$0.00 |
$0 | Many Generics | 2 |
Preferred Brand |
$30.00 | $60.00 | None | $107.69 |
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 |
Freedom Savings Plan Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$35.00 | $70.00 | None | $107.51 |
Browse Plan Formulary |
Freedom VIP Care (HMO SNP)
|
$0.00 |
$0 | Many Generics | 2 |
Preferred Brand |
$20.00 | $40.00 | None | $107.56 |
Browse Plan Formulary |
Freedom VIP Care COPD (HMO SNP)
|
$0.00 |
$0 | Many Generics | 2 |
Preferred Brand |
$20.00 | $40.00 | None | $107.56 |
Browse Plan Formulary |
Freedom VIP Savings (HMO SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$30.00 | $60.00 | None | $107.56 |
Browse Plan Formulary |
Freedom VIP Savings COPD (HMO SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$30.00 | $60.00 | None | $107.56 |
Browse Plan Formulary |
Humana Gold Plus H1036-025 (HMO)
|
$0.00 |
$0 | Some Generics, Few Brands | 3 |
Preferred Brand |
$10.00 | $20.00 | P | $129.94 |
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 |
Humana Gold Plus H1036-141 (HMO)
|
$0.00 |
$0 | Few Generics, Few Brands | 3 |
Preferred Brand |
$25.00 | $65.00 | P | $129.91 |
Browse Plan Formulary |
Humana Gold Plus SNP-DB H1036-160 (HMO SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 3 |
Preferred Brand |
$10.00 | $20.00 | P | $129.91 |
Browse Plan Formulary |
HumanaChoice R5826-074 (Regional PPO)
|
$0.00 |
$150* | Few Generics, Few Brands | 3* |
Preferred Brand |
$45.00 | $125.00 | P | $129.03 |
Browse Plan Formulary |
Optimum Diamond Rewards (HMO-POS SNP)
|
$0.00 |
$0 | Many Generics | 2 |
Preferred Brand |
$25.00 | $50.00 | None | $107.39 |
Browse Plan Formulary |
Optimum Diamond Rewards COPD (HMO-POS SNP)
|
$0.00 |
$0 | Many Generics | 2 |
Preferred Brand |
$25.00 | $50.00 | None | $107.39 |
Browse Plan Formulary |
Optimum Gold Rewards Plan (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Preferred Brand |
$30.00 | $60.00 | None | $107.66 |
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 |
Optimum Platinum Plan (HMO-POS)
|
$0.00 |
$0 | Many Generics | 2 |
Preferred Brand |
$5.00 | $10.00 | None | $107.66 |
Browse Plan Formulary |
Preferred Secure Option (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$6.00 | $12.00 | None | $99.47 |
Browse Plan Formulary |
Simply Extra (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$2.00 | $6.00 | P | $107.70 |
Browse Plan Formulary |
Simply Level (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 1 |
Preferred Generic |
$0.00 | $0.00 | P | $107.72 |
Browse Plan Formulary |
Simply More (HMO)
|
$0.00 |
$0 | Many Generics | 1 |
Preferred Generic |
$0.00 | $0.00 | P | $107.70 |
Browse Plan Formulary |
Sunrise (HMO)
|
$0.00 |
$0 | All Generics | 1 |
Generic |
$0.00 | $0.00 | None | $18.85 |
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 |
Humana Gold Plus SNP-DE H1036-102 (HMO SNP)
|
$8.60 |
$310 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $125.00 | P | $129.91 |
Browse Plan Formulary |
WellCare Liberty (HMO SNP)
|
$9.40 |
$310 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$4.00 | $8.00 | P | $103.68 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$10.40 |
$310 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$7.00 | $14.00 | P | $103.68 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-161 (HMO SNP)
|
$10.90 |
$310 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $125.00 | P | $129.91 |
Browse Plan Formulary |
CareNeeds PLUS (HMO SNP)
|
$11.40 |
$310 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $125.00 | P | $129.99 |
Browse Plan Formulary |
WellCare Select (HMO SNP)
|
$11.60 |
$310 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$4.00 | $8.00 | P | $104.72 |
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 LP (HMO SNP)
|
$17.00 |
$310 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $100.03 |
Browse Plan Formulary |
Sunny Days (HMO SNP)
|
$17.40 |
$0 | All Generics | 1 |
Generic |
$0.00 | $0.00 | None | $18.85 |
Browse Plan Formulary |
Coventry Summit Maximum (HMO SNP)
|
$17.70 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$76.00 | $228.00 | None | $78.58 |
Browse Plan Formulary |
CareNeeds (HMO SNP)
|
$18.70 |
$310 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $125.00 | P | $129.99 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$19.80 |
$310 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $99.28 |
Browse Plan Formulary |
Advantage by Sunshine Health (HMO SNP)
|
$21.00 |
$310* | No additional gap coverage, only the Donut Hole Discount | 1* |
Generic |
$0.00 | $0.00 | None | $99.92 |
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 RP (Regional PPO SNP)
|
$21.80 |
$310 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | None | $98.94 |
Browse Plan Formulary |
Freedom Medi-Medi Full (HMO SNP)
|
$22.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
n/a | n/a | None | $107.60 |
Browse Plan Formulary |
Freedom Medi-Medi Partial (HMO SNP)
|
$22.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $107.60 |
Browse Plan Formulary |
Optimum Emerald Full (HMO SNP)
|
$22.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
n/a | n/a | None | $107.63 |
Browse Plan Formulary |
Optimum Emerald Partial (HMO SNP)
|
$22.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $107.63 |
Browse Plan Formulary |
Simply Care (HMO SNP)
|
$22.10 |
$0 | Many Generics | 1 |
Preferred Generic |
$0.00 | n/a | P | $107.72 |
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 |
Simply Comfort (HMO SNP)
|
$22.10 |
$0 | Many Generics | 1 |
Preferred Generic |
$0.00 | n/a | P | $107.72 |
Browse Plan Formulary |
Simply Complete (HMO SNP)
|
$22.10 |
$310* | Many Generics | 1* |
Preferred Generic |
$0.00 | $0.00 | P | $107.72 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (PPO)
|
$35.00 |
$310 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$4.00 | $8.00 | None | $97.83 |
Browse Plan Formulary |
Clear Skies (HMO SNP)
|
$35.20 |
$0 | All Generics | 1 |
Generic |
$0.00 | $0.00 | None | $18.85 |
Browse Plan Formulary |
HumanaChoice R5826-005 (Regional PPO)
|
$36.60 |
$0 | Few Generics, Few Brands | 3 |
Preferred Brand |
$40.00 | $110.00 | P | $129.03 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$37.00 |
$310 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic |
$4.00 | $8.00 | None | $97.83 |
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 |
Humana Gold Choice H8145-061 (PFFS)
|
$103.00 |
$0 | Few Generics, Few Brands | 3 |
Preferred Brand |
$45.00 | $125.00 | P | $129.17 |
Browse Plan Formulary |