AMITRIPTYLINE HCL 25MG TABLET USP (100 CT) (100 BOT) (NDC: 00603221321)
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 | P | $5.58 |
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 | P | $5.58 |
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 | P | $5.60 |
Browse Plan Formulary |
BlueMedicare HMO LifeTime (HMO)
|
$0.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$80.00 | $240.00 | P | $7.96 |
Browse Plan Formulary |
BlueMedicare HMO PrimeTime (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$90.00 | $270.00 | P | $7.96 |
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 |
BlueMedicare Regional PPO (Regional PPO)
|
$0.00 |
$30 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Brand |
$95.00 | $285.00 | P | $7.97 |
Browse Plan Formulary |
Day Break (HMO)
|
$0.00 |
$0 | All Generics | 1 |
Generic |
$0.00 | $0.00 | None | $13.75 |
Browse Plan Formulary |
Freedom Medicare Plan Rx (HMO)
|
$0.00 |
$0 | Many Generics | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $5.19 |
Browse Plan Formulary |
Freedom Savings Plan Rx (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $5.20 |
Browse Plan Formulary |
Freedom VIP Care (HMO SNP)
|
$0.00 |
$0 | Many Generics | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $5.21 |
Browse Plan Formulary |
Freedom VIP Care COPD (HMO SNP)
|
$0.00 |
$0 | Many Generics | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $5.21 |
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 |
Freedom VIP Savings (HMO SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $5.21 |
Browse Plan Formulary |
Freedom VIP Savings COPD (HMO SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $5.21 |
Browse Plan Formulary |
Humana Gold Plus H1036-067 (HMO)
|
$0.00 |
$0 | Some Generics, Few Brands | 1 |
Preferred Generic |
$0.00 | $0.00 | P | $7.49 |
Browse Plan Formulary |
Humana Gold Plus H1036-141 (HMO)
|
$0.00 |
$0 | Few Generics, Few Brands | 1 |
Preferred Generic |
$0.00 | $0.00 | P | $7.49 |
Browse Plan Formulary |
Humana Gold Plus SNP-DB H1036-160 (HMO SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 1 |
Preferred Generic |
$0.00 | $0.00 | P | $7.49 |
Browse Plan Formulary |
HumanaChoice R5826-074 (Regional PPO)
|
$0.00 |
$150* | Few Generics, Few Brands | 1* |
Preferred Generic |
$6.00 | $0.00 | P | $7.49 |
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 Diamond Rewards (HMO-POS SNP)
|
$0.00 |
$0 | Many Generics | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $5.25 |
Browse Plan Formulary |
Optimum Diamond Rewards COPD (HMO-POS SNP)
|
$0.00 |
$0 | Many Generics | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $5.25 |
Browse Plan Formulary |
Optimum Gold Rewards Plan (HMO-POS)
|
$0.00 |
$0 | Many Generics | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $5.19 |
Browse Plan Formulary |
Optimum Gold Rewards Plan (HMO-POS)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $5.22 |
Browse Plan Formulary |
Optimum Platinum Plan (HMO-POS)
|
$0.00 |
$0 | Many Generics | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $5.22 |
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 | P | $5.58 |
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 Extra (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Preferred Generic |
$2.00 | $6.00 | P | $2.04 |
Browse Plan Formulary |
Simply Level (HMO SNP)
|
$0.00 |
$0 | Many Generics, Few Brands | 1 |
Preferred Generic |
$0.00 | $0.00 | P | $2.04 |
Browse Plan Formulary |
Simply More (HMO)
|
$0.00 |
$0 | Many Generics | 1 |
Preferred Generic |
$0.00 | $0.00 | P | $2.04 |
Browse Plan Formulary |
Sunrise (HMO)
|
$0.00 |
$0 | All Generics | 1 |
Generic |
$0.00 | $0.00 | None | $13.75 |
Browse Plan Formulary |
Ultimate Premier (HMO)
|
$0.00 |
$0 | Many Generics | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $7.84 |
Browse Plan Formulary |
Ultimate Premier Plus (HMO)
|
$0.00 |
$0 | Many Generics | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $7.84 |
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 | 1* |
Preferred Generic |
$0.00 | $0.00 | P | $7.49 |
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 | $4.17 |
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 | $4.17 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-161 (HMO SNP)
|
$10.90 |
$310* | No additional gap coverage, only the Donut Hole Discount | 1* |
Preferred Generic |
$0.00 | $0.00 | P | $7.49 |
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 | $4.15 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete LP (HMO SNP)
|
$17.00 |
$310 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | P | $5.58 |
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 Nursing Home Plan (PPO SNP)
|
$19.80 |
$310 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | P | $5.58 |
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 | $7.37 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP (Regional PPO SNP)
|
$21.80 |
$310 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
15% | 15% | P | $5.60 |
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 | $5.20 |
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 | $5.20 |
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 | $5.20 |
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 Emerald Partial (HMO SNP)
|
$22.10 |
$310 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
15% | 15% | None | $5.20 |
Browse Plan Formulary |
Simply Care (HMO SNP)
|
$22.10 |
$0 | Many Generics | 1 |
Preferred Generic |
$0.00 | n/a | P | $2.04 |
Browse Plan Formulary |
Simply Comfort (HMO SNP)
|
$22.10 |
$0 | Many Generics | 1 |
Preferred Generic |
$0.00 | n/a | P | $2.04 |
Browse Plan Formulary |
Simply Complete (HMO SNP)
|
$22.10 |
$310* | Many Generics | 1* |
Preferred Generic |
$0.00 | $0.00 | P | $2.04 |
Browse Plan Formulary |
HumanaChoice R5826-005 (Regional PPO)
|
$36.60 |
$0 | Few Generics, Few Brands | 1 |
Preferred Generic |
$3.00 | $0.00 | P | $7.49 |
Browse Plan Formulary |
Humana Gold Choice H8145-061 (PFFS)
|
$103.00 |
$0 | Few Generics, Few Brands | 1 |
Preferred Generic |
$6.00 | $0.00 | P | $7.49 |
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 |
BlueMedicare PPO (PPO)
|
$127.00 |
$0 | Many Generics | 4 |
Non-Preferred Brand |
$75.00 | $225.00 | P | $7.96 |
Browse Plan Formulary |