CHLORDIAZEPOXIDE AND AMITRIPTYLINE HCL TABLET 12.5-5MG (500 CT) (500 BOT) (NDC: 00378021105)
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 |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | None | $101.41 |
Browse Plan Formulary |
Aetna Medicare Value Plan (HMO)
|
$0.00 |
$0 |
Few Generics |
1 |
Generic |
$10.00 | $20.00 | None | $139.98 |
Browse Plan Formulary |
AvMed Medicare Choice (HMO)
|
$0.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | P | $136.50 |
Browse Plan Formulary |
AvMed Medicare Choice Elect (HMO)
|
$0.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$4.00 | $0.00 | P | $136.50 |
Browse Plan Formulary |
Coventry Summit Ideal (HMO)
|
$0.00 |
$0 |
Many Generics |
3 |
Non-Preferred Brand |
$35.00 | $105.00 | None | $154.34 |
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 Plus (HMO)
|
$0.00 |
$0 |
Many Generics |
3 |
Non-Preferred Brand |
$60.00 | $180.00 | None | $154.34 |
Browse Plan Formulary |
Coventry Vista Ideal (HMO)
|
$0.00 |
$0 |
Many Generics |
3 |
Non-Preferred Brand |
$30.00 | $90.00 | None | $154.34 |
Browse Plan Formulary |
Freedom Medicare Plan Rx (HMO)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $129.20 |
Browse Plan Formulary |
Freedom VIP Care (HMO SNP)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $129.77 |
Browse Plan Formulary |
Freedom VIP Care COPD (HMO SNP)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $129.77 |
Browse Plan Formulary |
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 | $129.77 |
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 COPD (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $129.77 |
Browse Plan Formulary |
Healthy Advantage Plan (HMO)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | n/a | P | $107.15 |
Browse Plan Formulary |
Leon Medical Centers Health Plans - Leon Cares (HMO)
|
$0.00 |
$0 |
Many Generics |
1 |
Generic |
$0.00 | n/a | None | $90.33 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax (HMO-POS)
|
$0.00 |
$0 |
Many Generics |
3 |
Non-Preferred Brand |
$25.00 | n/a | None | $101.33 |
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 | $129.40 |
Browse Plan Formulary |
Optimum Platinum Plan (HMO-POS)
|
$0.00 |
$0 |
Many Generics |
1 |
Preferred Generic |
$0.00 | $0.00 | None | $129.40 |
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 |
Preferred Choice Dade (HMO-POS)
|
$0.00 |
$0 |
Many Generics |
3 |
Non-Preferred Brand |
$25.00 | $65.00 | None | $101.33 |
Browse Plan Formulary |
Preferred Complete Care (HMO)
|
$0.00 |
$0 |
Many Generics, Some Brands |
3 |
Non-Preferred Brand |
$25.00 | $65.00 | None | $101.33 |
Browse Plan Formulary |
Preferred Special Care Miami-Dade (HMO SNP)
|
$0.00 |
$0 |
Many Generics |
3 |
Non-Preferred Brand |
$25.00 | $65.00 | None | $101.33 |
Browse Plan Formulary |
Simply Clear (HMO SNP)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Generic |
25% | n/a | P | $155.01 |
Browse Plan Formulary |
Simply Extra (HMO)
|
$0.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | P | $155.07 |
Browse Plan Formulary |
Simply Level (HMO SNP)
|
$0.00 |
$0 |
Many Generics, Few Brands |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | P | $155.07 |
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 More (HMO)
|
$0.00 |
$0 |
All Generics, All Brands |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | P | $155.07 |
Browse Plan Formulary |
Simply Options (HMO-POS)
|
$0.00 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$0.00 | $0.00 | P | $155.07 |
Browse Plan Formulary |
SunPlus Advantage Plan (HMO)
|
$0.00 |
$0 |
All Generics, All Brands |
1 |
Preferred Generic |
$0.00 | n/a | P | $107.15 |
Browse Plan Formulary |
SunPlus Diabetes Special Needs Plan (HMO SNP)
|
$0.00 |
$0 |
All Generics, All Brands |
1 |
Preferred Generic |
$0.00 | n/a | P | $107.15 |
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 | $151.86 |
Browse Plan Formulary |
WellCare Access (HMO SNP)
|
$12.80 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$7.00 | $14.00 | P | $153.49 |
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 |
WellCare Liberty (HMO SNP)
|
$17.80 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Non-Preferred Generic |
$8.00 | $16.00 | P | $153.49 |
Browse Plan Formulary |
Coventry Summit Maximum (HMO SNP)
|
$18.90 |
$0 |
Many Generics |
3 |
Non-Preferred Brand |
$76.00 | $228.00 | None | $156.50 |
Browse Plan Formulary |
UnitedHealthcare Nursing Home Plan (HMO SNP)
|
$19.90 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $100.79 |
Browse Plan Formulary |
Medica HealthCare Plans MedicareMax Plus (HMO-POS SNP)
|
$20.60 |
$0 |
Many Generics |
3 |
Non-Preferred Brand |
25% | n/a | None | $101.61 |
Browse Plan Formulary |
Advantage by Sunshine Health (HMO SNP)
|
$21.00 |
$310* |
Many Generics |
1* |
Generic |
$0.00 | $0.00 | None | $146.13 |
Browse Plan Formulary |
Preferred Medicare Assist (HMO-POS SNP)
|
$21.20 |
$0 |
Many Generics |
3 |
Non-Preferred Brand |
25% | 25% | None | $101.61 |
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 | $101.41 |
Browse Plan Formulary |
Coventry Vista Maximum (HMO SNP)
|
$22.10 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Non-Preferred Brand |
$76.00 | $228.00 | None | $156.49 |
Browse Plan Formulary |
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 | $156.55 |
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 | $129.44 |
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 | $129.44 |
Browse Plan Formulary |
MediMax (HMO)
|
$22.10 |
$310 |
Call plan for details |
1 |
Preferred Generic |
25% | n/a | P | $107.14 |
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 Full (HMO SNP)
|
$22.10 |
$310 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
n/a | n/a | None | $129.45 |
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 | $129.45 |
Browse Plan Formulary |
Simply Care (HMO SNP)
|
$22.10 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$0.00 | n/a | P | $155.07 |
Browse Plan Formulary |
Simply Comfort (HMO SNP)
|
$22.10 |
$0 |
Many Generics |
2 |
Non-Preferred Generic |
$0.00 | n/a | P | $155.07 |
Browse Plan Formulary |
Simply Complete (HMO SNP)
|
$22.10 |
$310* |
Many Generics |
2* |
Non-Preferred Generic |
$0.00 | $0.00 | P | $155.07 |
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 | $139.98 |
Browse Plan Formulary |