IMIPRAMINE PAMOATE 100MG CAPSULES (30 BOT ) (NDC: 00054027413)
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 | $180.65 |
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 | $180.65 |
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 | $180.65 |
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 | $180.65 |
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 | $180.65 |
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 | $176.89 |
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 | $268.10 |
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 | $303.70 |
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 | $262.97 |
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 | $320.32 |
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 | $289.23 |
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 | $289.23 |
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 | $303.70 |
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 | $262.97 |
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 | $320.32 |
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 | $268.10 |
Browse Plan Formulary |
HumanaChoice R5826-006 (Regional PPO)
|
$25.50 |
$400 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
25% | 25% | None | $401.70 |
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 | $180.65 |
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 | $180.65 |
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 | $180.65 |
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 | $180.65 |
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 | $180.65 |
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 | $176.89 |
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 |
HumanaChoice H5216-009 (PPO)
|
$69.00 |
$400 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $347.84 |
Browse Plan Formulary |
PriorityMedicare Value (HMO-POS)
|
$78.00 |
$75 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | P | $299.42 |
Browse Plan Formulary |
Paramount Elite - Enhanced Medical and Drug (HMO)
|
$87.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | n/a | P | $310.09 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$87.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | n/a | P | $298.30 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$87.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | n/a | P | $320.30 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$87.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | n/a | P | $311.27 |
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)
|
$87.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | n/a | P | $299.42 |
Browse Plan Formulary |
PriorityMedicare Merit (PPO)
|
$87.00 |
$75* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$10.00 | n/a | P | $307.90 |
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 | $180.65 |
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 | $180.65 |
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 | $180.65 |
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 | $180.65 |
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 | $180.65 |
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 | $176.89 |
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 | $176.89 |
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 | $180.65 |
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 | $180.65 |
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 | $180.65 |
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 | $180.65 |
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 | $180.65 |
Browse Plan Formulary |
PriorityMedicare (HMO-POS)
|
$160.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$8.00 | n/a | P | $299.42 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$174.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | n/a | P | $320.30 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$174.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | n/a | P | $299.42 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$174.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | n/a | P | $307.90 |
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 Select (PPO)
|
$174.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | n/a | P | $298.30 |
Browse Plan Formulary |
PriorityMedicare Select (PPO)
|
$174.50 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$7.00 | n/a | P | $311.27 |
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 | $180.65 |
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 | $180.65 |
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 | $180.65 |
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 | $180.65 |
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 | $180.65 |
Browse Plan Formulary |
HAP Senior Plus Option 2 (PPO)
|
$208.00 |
$150* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$10.00 | n/a | None | $176.89 |
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 | $176.89 |
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 | $180.65 |
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 | $180.65 |
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 | $180.65 |
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 | $180.65 |
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 | $180.65 |
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 | $180.65 |
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 | $180.65 |
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 | $180.65 |
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 | $180.65 |
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 Prestige (HMO-POS)
|
$308.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | n/a | P | $180.65 |
Browse Plan Formulary |