AMITRIPTYLINE HCL 10MG TABLET (1000 BOT) (NDC: 00603221232)
2017 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 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$18.00 | n/a | P | $5.75 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$18.00 | n/a | P | $5.75 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$18.00 | n/a | P | $5.75 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$18.00 | n/a | P | $5.75 |
Browse Plan Formulary |
BCN Advantage HMO-POS Basic (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$18.00 | n/a | P | $5.75 |
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 (HMO)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$11.00 | n/a | None | $7.07 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | P | $5.22 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | P | $5.22 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | P | $5.27 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | P | $5.21 |
Browse Plan Formulary |
PriorityMedicare Key (HMO-POS)
|
$0.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | P | $5.26 |
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 Ideal (PPO)
|
$18.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | P | $5.22 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | P | $5.27 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | P | $5.22 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | P | $5.26 |
Browse Plan Formulary |
PriorityMedicare Ideal (PPO)
|
$18.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | P | $5.21 |
Browse Plan Formulary |
HumanaChoice R5826-006 (Regional PPO)
|
$25.50 |
$400 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
25% | 25% | None | $4.37 |
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 Essential (PPO)
|
$25.50 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | None | $5.75 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$25.50 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | None | $5.75 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$25.50 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | None | $5.75 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$25.50 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | None | $5.75 |
Browse Plan Formulary |
Medicare Plus Blue PPO Essential (PPO)
|
$25.50 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | None | $5.75 |
Browse Plan Formulary |
HAP Senior Plus Option 1 (HMO-POS)
|
$48.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$11.00 | n/a | None | $7.07 |
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 |
PriorityMedicare Value (HMO-POS)
|
$66.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | P | $5.32 |
Browse Plan Formulary |
HumanaChoice H5216-009 (PPO)
|
$69.00 |
$400* | Yes, but No Gap Coverage for this drug. | 3* |
Preferred Brand |
$47.00 | $131.00 | None | $4.37 |
Browse Plan Formulary |
McLaren Advantage Sapphire (HMO)
|
$73.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$85.00 | n/a | P | $4.91 |
Browse Plan Formulary |
McLaren Advantage Sapphire (HMO)
|
$73.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$85.00 | n/a | P | $4.87 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$85.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | n/a | P | $5.28 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$85.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | n/a | P | $5.29 |
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 Merit (PPO)
|
$85.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | n/a | P | $5.32 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$85.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | n/a | P | $5.31 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$85.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | n/a | P | $5.34 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$88.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | None | $5.75 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$88.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | None | $5.75 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$88.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | None | $5.75 |
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 Vitality (PPO)
|
$88.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | None | $5.75 |
Browse Plan Formulary |
Medicare Plus Blue PPO Vitality (PPO)
|
$88.00 |
$400 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | n/a | None | $5.75 |
Browse Plan Formulary |
HAP Senior Plus Option 2 (HMO-POS)
|
$97.00 |
$100* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | n/a | None | $7.07 |
Browse Plan Formulary |
HAP Senior Plus Option 1 (PPO)
|
$124.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$15.00 | n/a | None | $7.07 |
Browse Plan Formulary |
McLaren Advantage Diamond (HMO)
|
$132.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$85.00 | n/a | P | $4.91 |
Browse Plan Formulary |
McLaren Advantage Diamond (HMO)
|
$132.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$85.00 | n/a | P | $4.87 |
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)
|
$147.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | P | $5.75 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$147.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | P | $5.75 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$147.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | P | $5.75 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$147.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | P | $5.75 |
Browse Plan Formulary |
BCN Advantage HMO-POS Classic (HMO-POS)
|
$147.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | P | $5.75 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$155.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$8.00 | n/a | P | $5.32 |
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 |
McLaren Advantage Diamond + (HMO)
|
$160.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$85.00 | n/a | P | $4.87 |
Browse Plan Formulary |
McLaren Advantage Diamond + (HMO)
|
$160.00 |
$150 | No additional gap coverage, only the Donut Hole Discount | 3 |
Non-Preferred Brand |
$85.00 | n/a | P | $4.91 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$181.00 |
$105* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | n/a | None | $5.75 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$181.00 |
$105* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | n/a | None | $5.75 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$181.00 |
$105* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | n/a | None | $5.75 |
Browse Plan Formulary |
Medicare Plus Blue PPO Signature (PPO)
|
$181.00 |
$105* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | n/a | None | $5.75 |
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)
|
$181.00 |
$105* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$15.00 | n/a | None | $5.75 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$182.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | n/a | P | $5.34 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$182.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | n/a | P | $5.28 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$182.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | n/a | P | $5.32 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$182.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | n/a | P | $5.29 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$182.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | n/a | P | $5.31 |
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 Option 2 (PPO)
|
$208.00 |
$150* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$10.00 | n/a | None | $7.07 |
Browse Plan Formulary |
HAP Senior Plus Option 3 (HMO-POS)
|
$218.00 |
$50* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$10.00 | n/a | None | $7.07 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$271.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$14.00 | n/a | None | $5.75 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$271.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$14.00 | n/a | None | $5.75 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$271.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$14.00 | n/a | None | $5.75 |
Browse Plan Formulary |
Medicare Plus Blue PPO Assure (PPO)
|
$271.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$14.00 | n/a | None | $5.75 |
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)
|
$271.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$14.00 | n/a | None | $5.75 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$308.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | P | $5.75 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$308.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | P | $5.75 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$308.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | P | $5.75 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$308.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | P | $5.75 |
Browse Plan Formulary |
BCN Advantage HMO-POS Prestige (HMO-POS)
|
$308.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | P | $5.75 |
Browse Plan Formulary |