AMITRIPTYLINE HCL 150 MG TABLET (100.000 EA ) (NDC: 16729017601)
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 Plan 6 (HMO)
|
$0.00 |
$195 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $70.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Walgreens (PPO)
|
$0.00 |
$250 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $70.20 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Aetna Medicare Premier (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $44.10 |
Browse Plan Formulary |
Aetna Medicare Value Plan (PPO)
|
$0.00 |
$150* |
Yes, but No Gap Coverage for this drug. |
3* |
Preferred Brand |
$47.00 | $141.00 | P | $42.90 |
Browse Plan Formulary |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | None | $35.40 |
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 |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | None | $35.10 |
Browse Plan Formulary |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | None | $37.20 |
Browse Plan Formulary |
Anthem MediBlue Preferred (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | None | $36.90 |
Browse Plan Formulary |
Humana Gold Plus H6622-021 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $0.00 | None | $10.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H6622-021 (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $0.00 | None | $10.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
HumanaChoice H5216-285 (PPO)
|
$0.00 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $0.00 | None | $10.50 |
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 H5525-042 (PPO)
|
$0.00 |
$250* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$17.00 | $0.00 | None | $10.50 |
Browse Plan Formulary |
MediGold Essential Care (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $58.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MediGold Essential Care (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $58.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MediGold Essential Care (HMO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $58.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $47.70 |
Browse Plan Formulary |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $47.70 |
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 |
MedMutual Advantage Classic (HMO)
|
$0.00 |
$95* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $47.70 |
Browse Plan Formulary |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $53.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Reid Health Alliance Medicare HMO Basic Rx 2 (HMO)
|
$0.00 |
$100 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P | $19.20 |
Browse Plan Formulary select insulin pay $15-$35 copay but not this drug |
Wellcare Dividend Giveback (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $45.30 |
Browse Plan Formulary |
Wellcare Giveback (HMO)
|
$0.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
48% | 48% | None | $56.70 |
Browse Plan Formulary |
Wellcare Giveback Boost (HMO)
|
$0.00 |
$75 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $57.00 |
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 (HMO)
|
$0.00 |
$75 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $56.70 |
Browse Plan Formulary |
Wellcare No Premium Essential (HMO-POS)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $45.30 |
Browse Plan Formulary |
Wellcare No Premium Medicare (HMO)
|
$0.00 |
$75 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$90.00 | $180.00 | None | $57.00 |
Browse Plan Formulary |
Wellcare No Premium Open (PPO)
|
$0.00 |
$160 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
43% | 43% | None | $57.00 |
Browse Plan Formulary |
Humana Gold Plus - Diabetes and Heart (HMO C-SNP)
|
$16.00 |
$200* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$17.00 | $0.00 | None | $10.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Wellcare Assist (HMO)
|
$16.80 |
$480 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
42% | 42% | None | $42.90 |
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 |
Wellcare Assist Complement (HMO)
|
$17.60 |
$480 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
42% | 42% | None | $43.20 |
Browse Plan Formulary |
Anthem MediBlue Preferred Plus (HMO)
|
$19.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | None | $36.30 |
Browse Plan Formulary |
HumanaChoice H5216-109 (PPO)
|
$19.00 |
$150* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$8.00 | $0.00 | None | $10.50 |
Browse Plan Formulary |
AARP Medicare Advantage Plan 2 (HMO)
|
$20.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $56.40 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
AARP Medicare Advantage Plan 2 (HMO)
|
$20.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $70.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Humana Gold Plus H6622-055 (HMO)
|
$20.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$5.00 | $0.00 | None | $10.50 |
Browse Plan Formulary select insulin pay $35 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 |
Anthem MediBlue Extra (HMO)
|
$22.00 |
$480 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$7.00 | $0.00 | None | $36.30 |
Browse Plan Formulary |
Aetna Medicare Assure 1 (HMO D-SNP)
|
$23.20 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $42.60 |
Browse Plan Formulary |
Humana Gold Plus SNP-DE H6622-015 (HMO D-SNP)
|
$27.60 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$18.00 | $0.00 | None | $10.50 |
Browse Plan Formulary |
Wellcare Dual Access Extra (HMO-POS D-SNP)
|
$31.10 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
47% | 47% | None | $60.90 |
Browse Plan Formulary |
Wellcare Dual Access (HMO D-SNP)
|
$32.00 |
$480 |
Some Generics |
4 |
Non-Preferred Drug |
50% | 50% | None | $42.90 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete (HMO-POS D-SNP)
|
$33.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $55.20 |
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 |
Aetna Medicare Premier Plus 2 (Regional PPO)
|
$33.40 |
$260 |
No |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $42.90 |
Browse Plan Formulary |
Anthem MediBlue Dual Advantage (HMO D-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$20.00 | $60.00 | None | $36.30 |
Browse Plan Formulary |
CareSource Dual Advantage (HMO D-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
25% | 25% | None | $18.30 |
Browse Plan Formulary |
Molina Medicare Complete Care (HMO D-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$44.00 | $132.00 | None | $53.40 |
Browse Plan Formulary |
UnitedHealthcare Dual Complete LP1 (HMO D-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $55.20 |
Browse Plan Formulary |
Valor Health Plan (HMO I-SNP)
|
$33.50 |
$480 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
25% | n/a | None | $49.50 |
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 |
Anthem MediBlue Access Basic (Regional PPO)
|
$41.50 |
$200* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$15.00 | $0.00 | None | $36.30 |
Browse Plan Formulary |
Aetna Medicare Premier Plus 1 (Regional PPO)
|
$44.50 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$42.00 | $126.00 | P | $42.60 |
Browse Plan Formulary |
CareSource Advantage (HMO)
|
$45.00 |
$100* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $20.00 | None | $18.30 |
Browse Plan Formulary |
HumanaChoice R5495-002 (Regional PPO)
|
$47.80 |
$480* |
No |
2* |
Generic |
$20.00 | $0.00 | None | $10.50 |
Browse Plan Formulary |
MediGold True Advantage (HMO)
|
$49.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $58.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
Reid Health Alliance Medicare HMO Rx (HMO)
|
$51.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
50% | 50% | P | $19.20 |
Browse Plan Formulary select insulin pay $15-$35 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 |
Anthem MediBlue Plus (HMO)
|
$55.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$10.00 | $0.00 | None | $36.90 |
Browse Plan Formulary |
Anthem MediBlue Access (PPO)
|
$56.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$15.00 | $0.00 | None | $36.30 |
Browse Plan Formulary |
HumanaChoice H5216-023 (PPO)
|
$58.00 |
$100* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$17.00 | $0.00 | None | $10.50 |
Browse Plan Formulary |
Humana Gold Choice H8145-032 (PFFS)
|
$83.00 |
$225* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$17.00 | $0.00 | None | $10.50 |
Browse Plan Formulary |
Anthem MediBlue Access Plus (PPO)
|
$89.00 |
$40* |
Yes, but No Gap Coverage for this drug. |
2* |
Generic |
$15.00 | $0.00 | None | $36.60 |
Browse Plan Formulary |
Humana Gold Plus H6622-019 (HMO)
|
$91.00 |
$125* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$4.00 | $0.00 | None | $10.50 |
Browse Plan Formulary select insulin pay $35 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 |
MedMutual Advantage Choice (HMO)
|
$100.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $47.70 |
Browse Plan Formulary |
MedMutual Advantage Choice (HMO)
|
$100.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $47.70 |
Browse Plan Formulary |
MedMutual Advantage Choice (HMO)
|
$100.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $47.70 |
Browse Plan Formulary |
MedMutual Advantage Select (PPO)
|
$100.00 |
$95* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $47.70 |
Browse Plan Formulary |
MedMutual Advantage Select (PPO)
|
$100.00 |
$95* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $47.70 |
Browse Plan Formulary |
MedMutual Advantage Select (PPO)
|
$100.00 |
$95* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $47.70 |
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 |
AARP Medicare Advantage Plan 3 (HMO)
|
$111.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $65.70 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MediGold Classic Preferred (HMO)
|
$120.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $58.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MediGold Classic Preferred (HMO)
|
$120.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $58.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MediGold Classic Preferred (HMO)
|
$120.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$45.00 | $90.00 | None | $58.50 |
Browse Plan Formulary select insulin pay $35 copay but not this drug |
MedMutual Advantage Plus (HMO)
|
$134.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $47.70 |
Browse Plan Formulary |
MedMutual Advantage Plus (HMO)
|
$134.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $47.70 |
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 |
MedMutual Advantage Plus (HMO)
|
$134.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $47.70 |
Browse Plan Formulary |
MedMutual Advantage Preferred (PPO)
|
$150.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $47.70 |
Browse Plan Formulary |
MedMutual Advantage Preferred (PPO)
|
$150.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $47.70 |
Browse Plan Formulary |
MedMutual Advantage Preferred (PPO)
|
$150.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $47.70 |
Browse Plan Formulary |
HumanaChoice H5525-030 (PPO)
|
$151.00 |
$100* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$4.00 | $0.00 | None | $10.50 |
Browse Plan Formulary |
MedMutual Advantage Premium (PPO)
|
$200.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $47.70 |
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 |
MedMutual Advantage Premium (PPO)
|
$200.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $47.70 |
Browse Plan Formulary |
MedMutual Advantage Premium (PPO)
|
$200.00 |
$55* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $10.00 | None | $47.70 |
Browse Plan Formulary |