IMIPRAMINE HCL 10MG TABLET (100 CT) (100 BOT) (NDC: 49884005401)
2022 Medicare Prescription Drug Plan (MAPD) Information
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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 Medicare Advantage (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $6.90 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Walgreens (PPO)
|
$0.00 |
$345 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $7.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Plus Plan (PPO)
|
$0.00 |
$300 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | P | $8.40 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$0.00 |
$250 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | P | $9.60 |
Browse Plan Formulary |
Amerivantage Classic (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$10.00 | $0.00 | P | $4.20 |
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 |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$12.00 | $0.00 | P | $3.90 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$12.00 | $0.00 | P | $4.50 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$12.00 | $0.00 | P | $4.20 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$12.00 | $0.00 | P | $3.90 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$12.00 | $0.00 | P | $4.50 |
Browse Plan Formulary |
Amerivantage Classic Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$12.00 | $0.00 | P | $4.20 |
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 |
Ascension Complete Seton Access (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$5.00 | $0.00 | None | $3.90 |
Browse Plan Formulary |
Ascension Complete Seton Access Plus (PPO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$5.00 | $0.00 | None | $3.90 |
Browse Plan Formulary |
Ascension Complete Seton Reward (HMO)
|
$0.00 |
$480* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$5.00 | $0.00 | None | $3.90 |
Browse Plan Formulary |
Ascension Complete Seton Secure (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 2 |
Generic |
$1.00 | $0.00 | None | $3.90 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Choice Plus (PPO)
|
$0.00 |
$480 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | None | $6.90 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Classic (PPO)
|
$0.00 |
$480 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | None | $6.30 |
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 |
Blue Cross Medicare Advantage Value (HMO)
|
$0.00 |
$100* | Yes, but No Gap Coverage for this drug. | 3* |
Preferred Brand |
$47.00 | $94.00 | None | $6.60 |
Browse Plan Formulary |
BSW SeniorCare Advantage Select Rx (HMO)
|
$0.00 |
$300 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$100.00 | $200.00 | None | $4.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H0028-037 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $3.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Imperial Insurance Company Traditional (HMO)
|
$0.00 |
$0 | Yes, this drug has Gap Coverage. | 1 |
Preferred Generic |
$0.00 | $0.00 | None | $5.40 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
Imperial Insurance Traditional Plus (HMO)
|
$0.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
25% | 25% | None | $5.40 |
Browse Plan Formulary |
Imperial Insurance Value (HMO C-SNP)
|
$0.00 |
$0 | Many Generics, Some Brands | 2 |
Generic |
$5.00 | $10.00 | None | $5.40 |
Browse Plan Formulary select insulin pay $0 copay but not this drug |
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 Chronic Complete (HMO C-SNP)
|
$0.00 |
$0 | Some Generics, Few Brands | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $6.60 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
UnitedHealthcare Dual Complete Choice (Regional PPO D-SNP)
|
$0.00 |
$480 | No | 4 |
Tier 4 |
$0.00 | $0.00 | None | $7.50 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$2.00 | $0.00 | None | $4.80 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$2.00 | $0.00 | None | $3.90 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$2.00 | $0.00 | None | $3.30 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$300* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$2.00 | $0.00 | None | $3.30 |
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 Giveback (HMO)
|
$0.00 |
$300* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$2.00 | $0.00 | None | $3.30 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $4.80 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $3.90 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $3.30 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $3.30 |
Browse Plan Formulary |
Wellcare No Premium (HMO-POS)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Generic |
$0.00 | $0.00 | None | $3.30 |
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 No Premium Rx Plus Open (PPO)
|
$0.00 |
$300* | No additional gap coverage, only the Donut Hole Discount | 2* |
Generic |
$0.00 | $0.00 | None | $3.30 |
Browse Plan Formulary |
Wellcare TexanPlus No Premium (HMO)
|
$0.00 |
$200* | Yes, but No Gap Coverage for this drug. | 2* |
Generic |
$0.00 | $0.00 | None | $3.30 |
Browse Plan Formulary |
UnitedHealthcare Medicare Silver (Regional PPO C-SNP)
|
$3.70 |
$480 | No | 4 |
Tier 4 |
25% | 25% | None | $7.50 |
Browse Plan Formulary |
UnitedHealthcare Medicare Gold (Regional PPO C-SNP)
|
$10.80 |
$295 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $7.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Complement Assist (HMO)
|
$14.90 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $0.00 | None | $8.70 |
Browse Plan Formulary |
Aetna Medicare Choice Plan (PPO)
|
$15.00 |
$300 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $141.00 | P | $8.40 |
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 |
Aetna Medicare Dual Complete Plan (HMO D-SNP)
|
$18.00 |
$480 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $141.00 | P | $9.90 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Dual Care Plus (HMO D-SNP)
|
$18.80 |
$480 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $6.30 |
Browse Plan Formulary |
Wellcare Low Premium Open (PPO)
|
$20.00 |
$200* | Yes, this drug has Gap Coverage. | 2* |
Generic |
$1.00 | $0.00 | None | $3.30 |
Browse Plan Formulary |
Wellcare Assist (HMO)
|
$20.60 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $0.00 | None | $7.20 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete Focus (HMO D-SNP)
|
$21.30 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | None | $6.60 |
Browse Plan Formulary |
Amerivantage Dual Coordination (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $60.00 | P | $4.20 |
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 |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $60.00 | P | $4.20 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $60.00 | P | $4.50 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $60.00 | P | $3.90 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $60.00 | P | $4.20 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $60.00 | P | $4.50 |
Browse Plan Formulary |
Amerivantage Dual Coordination Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $60.00 | P | $3.90 |
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 |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $60.00 | P | $3.90 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $60.00 | P | $4.50 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $60.00 | P | $4.20 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $60.00 | P | $3.90 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $60.00 | P | $4.50 |
Browse Plan Formulary |
Amerivantage Dual Secure Plus (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$20.00 | $60.00 | P | $4.20 |
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 |
Amerivantage ESRD Care (HMO-POS C-SNP)
|
$25.10 |
$100 | Few Generics | 2 |
Generic |
$7.00 | $0.00 | P | $3.90 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H0028-044 (HMO D-SNP)
|
$25.10 |
$460 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $3.00 |
Browse Plan Formulary |
Imperial Insurance Company Dual (HMO D-SNP)
|
$25.10 |
$480* | Many Generics, Some Brands | 1* |
Preferred Generic |
0% | 0% | None | $5.40 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | None | $7.80 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | None | $6.30 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
15% | 15% | None | $6.30 |
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 I-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Tier 4 |
25% | 25% | None | $6.90 |
Browse Plan Formulary |
Wellcare Dual Access Harmony (HMO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$10.00 | $0.00 | None | $8.70 |
Browse Plan Formulary |
Wellcare Dual Access Open (PPO D-SNP)
|
$25.10 |
$480 | No additional gap coverage, only the Donut Hole Discount | 2 |
Generic |
$5.00 | $0.00 | None | $7.20 |
Browse Plan Formulary |
BSW SeniorCare Advantage Basic (PPO)
|
$37.00 |
$250 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$99.00 | $198.00 | None | $4.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H0473-003 (PPO)
|
$38.00 |
$200* | No additional gap coverage, only the Donut Hole Discount | 3* |
Preferred Brand |
$47.00 | $131.00 | None | $3.00 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice R4182-004 (Regional PPO)
|
$43.60 |
$175 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $3.30 |
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 Medicare Advantage Choice (Regional PPO)
|
$49.00 |
$395 | Yes, but No Gap Coverage for this drug. | 4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $7.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice R4182-003 (Regional PPO)
|
$51.00 |
$175 | No | 3 |
Preferred Brand |
$47.00 | $131.00 | None | $3.30 |
Browse Plan Formulary |
Blue Cross Medicare Advantage Choice Premier (PPO)
|
$90.00 |
$300 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$47.00 | $94.00 | None | $6.90 |
Browse Plan Formulary |
BSW SeniorCare Advantage Platinum (PPO)
|
$140.00 |
$50 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $4.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
BSW SeniorCare Advantage Preferred Rx (HMO)
|
$145.00 |
$100 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $4.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Blue Cross Medicare Advantage Flex (PPO)
|
$215.40 |
$480 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
33% | 33% | None | $6.30 |
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 |
BSW SeniorCare Advantage Premium Rx (HMO)
|
$255.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 4 |
Non-Preferred Drug |
$95.00 | $190.00 | None | $4.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |