DEXTROAMPHETAMINE SULFATE CAPSULES EXTENDED RELEASED 15MG 100 CAPSULES BOT (100 CAPSULES BOT) (NDC: 00555095602)
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 Choice Plan 2 (Regional PPO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $123.41 |
Browse Plan Formulary |
AARP MedicareComplete Plus (HMO-POS)
|
$0.00 |
$0 |
Few Generics |
3 |
Preferred Brand |
$45.00 | $125.00 | None | $122.98 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$0 |
Few Generics |
1 |
Generic |
$10.00 | $20.00 | P Q:4 /1Days | $139.80 |
Browse Plan Formulary |
AvMed Medicare Choice (HMO)
|
$0.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$4.00 | $0.00 | Q:120 /30Days | $132.05 |
Browse Plan Formulary |
BlueMedicare HMO LifeTime (HMO)
|
$0.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | Q:120 /30Days | $143.16 |
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 HMO PrimeTime (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | Q:120 /30Days | $143.16 |
Browse Plan Formulary |
BlueMedicare Regional PPO (Regional PPO)
|
$0.00 |
$30 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$33.00 | $99.00 | Q:120 /30Days | $143.30 |
Browse Plan Formulary |
CareDirect (HMO SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
3 |
Preferred Brand |
$20.00 | $50.00 | Q:120 /30Days | $128.69 |
Browse Plan Formulary |
CareFree PLUS (HMO)
|
$0.00 |
$0 |
Few Generics, Few Brands |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:120 /30Days | $128.69 |
Browse Plan Formulary |
CareHeart (HMO SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
3 |
Preferred Brand |
$20.00 | $50.00 | Q:120 /30Days | $128.69 |
Browse Plan Formulary |
CareOne (HMO)
|
$0.00 |
$0 |
Some Generics, Few Brands |
3 |
Preferred Brand |
$20.00 | $50.00 | Q:120 /30Days | $128.69 |
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 |
Coventry Summit Ideal (HMO)
|
$0.00 |
$0 |
Many Generics |
3 |
Non-Preferred Brand |
$45.00 | $135.00 | None | $140.68 |
Browse Plan Formulary |
Coventry Vista Ideal (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$75.00 | $225.00 | None | $140.68 |
Browse Plan Formulary |
Freedom Medicare Plan Rx (HMO)
|
$0.00 |
$0 |
Many Generics |
2 |
Preferred Brand |
$30.00 | $60.00 | P Q:120 /30Days | $161.06 |
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 | P Q:120 /30Days | $160.46 |
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 | P Q:120 /30Days | $160.75 |
Browse Plan Formulary |
Healthy Advantage Plan (HMO)
|
$0.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$0.00 | n/a | None | $138.47 |
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 |
Humana Gold Plus H1036-065C (HMO)
|
$0.00 |
$0 |
Some Generics, Few Brands |
3 |
Preferred Brand |
$20.00 | $50.00 | Q:120 /30Days | $128.69 |
Browse Plan Formulary |
Humana Gold Plus H1036-224 (HMO)
|
$0.00 |
$0 |
Few Generics, Few Brands |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:120 /30Days | $128.69 |
Browse Plan Formulary |
Humana Gold Plus SNP-CVD/CHF H1036-186 (HMO SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
3 |
Preferred Brand |
$20.00 | $50.00 | Q:120 /30Days | $128.69 |
Browse Plan Formulary |
Humana Gold Plus SNP-DB H1036-121C (HMO SNP)
|
$0.00 |
$0 |
Some Generics, Few Brands |
3 |
Preferred Brand |
$20.00 | $50.00 | Q:120 /30Days | $128.69 |
Browse Plan Formulary |
HumanaChoice R5826-074 (Regional PPO)
|
$0.00 |
$150 |
Few Generics, Few Brands |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:120 /30Days | $128.69 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax (HMO)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | n/a | P | $122.98 |
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 Gold Rewards Plan (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
$30.00 | $60.00 | P Q:120 /30Days | $161.26 |
Browse Plan Formulary |
Optimum Platinum Plan (HMO-POS)
|
$0.00 |
$0 |
Many Generics |
2 |
Preferred Brand |
$5.00 | $10.00 | P Q:120 /30Days | $161.26 |
Browse Plan Formulary |
PHP (HMO SNP)
|
$0.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Preferred Brand |
25% | n/a | P Q:120 /30Days | $155.38 |
Browse Plan Formulary |
Preferred Choice Broward (HMO)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | P | $122.98 |
Browse Plan Formulary |
Simply Clear (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
25% | n/a | Q:120 /30Days | $132.47 |
Browse Plan Formulary |
Simply Extra (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | Q:120 /30Days | $132.47 |
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 |
Simply Level (HMO SNP)
|
$0.00 |
$0 |
Many Generics, Few Brands |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | Q:120 /30Days | $132.47 |
Browse Plan Formulary |
Simply More (HMO)
|
$0.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | Q:120 /30Days | $132.47 |
Browse Plan Formulary |
Simply Options (HMO-POS)
|
$0.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | Q:120 /30Days | $132.47 |
Browse Plan Formulary |
SunPlus Advantage Plan (HMO)
|
$0.00 |
$0 |
All Generics, All Brands |
2 |
Non-Preferred Generic |
$0.00 | n/a | None | $138.47 |
Browse Plan Formulary |
SunPlus Diabetes Special Needs Plan (HMO SNP)
|
$0.00 |
$0 |
All Generics, All Brands |
2 |
Non-Preferred Generic |
$0.00 | n/a | None | $138.47 |
Browse Plan Formulary |
Humana Gold Plus SNP-I H1036-185 (HMO SNP)
|
$7.70 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:120 /30Days | $128.69 |
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 |
Humana Gold Plus SNP-DE H1036-103A (HMO SNP)
|
$8.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:120 /30Days | $128.69 |
Browse Plan Formulary |
WellCare Liberty (HMO SNP)
|
$9.40 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$88.00 | $176.00 | P | $158.82 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$10.40 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$84.00 | $168.00 | P | $158.82 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H1036-162 (HMO SNP)
|
$10.50 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:120 /30Days | $128.69 |
Browse Plan Formulary |
WellCare Select (HMO SNP)
|
$11.60 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Brand |
$88.00 | $176.00 | P | $159.42 |
Browse Plan Formulary |
CareNeeds PLUS (HMO SNP)
|
$11.70 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:120 /30Days | $128.69 |
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 |
CareNeeds (HMO SNP)
|
$17.00 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$45.00 | $125.00 | Q:120 /30Days | $128.69 |
Browse Plan Formulary |
Coventry Summit Maximum (HMO SNP)
|
$18.90 |
$0 |
Many Generics |
3 |
Non-Preferred Brand |
$76.00 | $228.00 | None | $140.38 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (PPO SNP)
|
$19.80 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
25% | 25% | None | $123.27 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax Plus (HMO-POS SNP)
|
$20.60 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | n/a | P | $123.71 |
Browse Plan Formulary |
Preferred Medicare Assist (HMO-POS SNP)
|
$21.20 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | P | $123.71 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete RP (Regional PPO SNP)
|
$21.80 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Tier 3 |
15% | 15% | None | $123.41 |
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 |
Coventry Vista Maximum Choice (HMO SNP)
|
$22.10 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$76.00 | $228.00 | None | $140.38 |
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 | P Q:120 /30Days | $161.16 |
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% | P Q:120 /30Days | $161.16 |
Browse Plan Formulary |
MediMax (HMO)
|
$22.10 |
$310 |
Call plan for details |
2 |
Non-Preferred Generic |
25% | n/a | None | $137.85 |
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 | P Q:120 /30Days | $161.51 |
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% | P Q:120 /30Days | $161.51 |
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 Care (HMO SNP)
|
$22.10 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$0.00 | n/a | Q:120 /30Days | $132.47 |
Browse Plan Formulary |
Simply Comfort (HMO SNP)
|
$22.10 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$0.00 | n/a | Q:120 /30Days | $132.47 |
Browse Plan Formulary |
Simply Complete (HMO SNP)
|
$22.10 |
$310* |
Many Generics |
2* |
Non-Preferred Generic |
$0.00 | $0.00 | Q:120 /30Days | $132.47 |
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 | P Q:4 /1Days | $138.70 |
Browse Plan Formulary |
HumanaChoice R5826-005 (Regional PPO)
|
$36.60 |
$0 |
Few Generics, Few Brands |
4 |
Non-Preferred Brand |
$85.00 | $245.00 | Q:120 /30Days | $128.69 |
Browse Plan Formulary |
HumanaChoice H5415-056 (PPO)
|
$45.00 |
$0 |
Few Generics, Few Brands |
4 |
Non-Preferred Brand |
$85.00 | $245.00 | Q:120 /30Days | $128.69 |
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 |
Humana Gold Choice H8145-061 (PFFS)
|
$103.00 |
$0 |
Few Generics, Few Brands |
4 |
Non-Preferred Brand |
$95.00 | $275.00 | Q:120 /30Days | $128.69 |
Browse Plan Formulary |
BlueMedicare PPO (PPO)
|
$127.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$5.00 | $15.00 | Q:120 /30Days | $143.74 |
Browse Plan Formulary |