AMITRIPTYLINE HCL 25 MG TABLET [Elavil] (30 TABLETS ) (NDC: 16729017217)
2024 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 from UHC WA-0002 (PPO)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $10.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC WA-0006 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $10.41 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC WA-0007 (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $10.43 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Elite Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $4.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Extra Value Plan (HMO-POS)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $4.00 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 Preferred Plan (PPO)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $4.10 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare SmartFit Plan (PPO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$10.00 | $10.00 | P | $4.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Value Plan (HMO-POS)
|
$0.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $4.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Health Plan of WA MA Plan 1 (HMO)
|
$0.00 |
$230* |
No additional gap coverage, only the Donut Hole Discount |
2* |
Generic |
$10.00 | $20.00 | None | $6.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H2486-006 (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $2.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H5619-063 (HMO)
|
$0.00 |
$500* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$15.00 | $0.00 | None | $2.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
|
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 H5216-247 (PPO)
|
$0.00 |
$125* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$8.00 | $0.00 | None | $2.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $1.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Choice Care (HMO)
|
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$47.00 | $94.00 | None | $1.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Premera Blue Cross Medicare Advantage (HMO)
|
$0.00 |
$160 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$42.00 | $126.00 | None | $6.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Providence Medicare Pine + Rx (HMO)
|
$0.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$10.00 | $10.00 | None | $4.77 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence BlueAdvantage HMO (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $3.77 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 |
Regence BlueAdvantage HMO (HMO)
|
$0.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $3.18 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence MedAdvantage + Rx Core (PPO)
|
$0.00 |
$375 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $3.53 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Giveback (HMO)
|
$0.00 |
$440 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $9.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Mutual of Omaha No Premium Open (PPO)
|
$0.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $9.09 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare No Premium (HMO)
|
$0.00 |
$150 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $9.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Kidney Care (HMO C-SNP)
|
$0.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
2 |
Generic |
$15.00 | $0.00 | None | $4.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 (HMO)
|
$14.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
44% | 44% | None | $9.16 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access (HMO D-SNP)
|
$20.70 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $9.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Liberty (HMO D-SNP)
|
$24.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $9.14 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Mutual of Omaha Low Premium Open (PPO)
|
$29.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
50% | 50% | None | $9.09 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellpoint Dual Advantage (HMO D-SNP)
|
$29.20 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
15% | 15% | None | $3.31 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Nursing Home Plan WA-F001 (PPO I-SNP)
|
$29.90 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
25% | 25% | None | $10.48 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 |
Molina Medicare Complete Care Select (HMO D-SNP)
|
$33.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $1.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Molina Medicare Complete Care (HMO D-SNP)
|
$33.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $1.67 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Value Plus H5619-134 (HMO)
|
$34.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
25% | 25% | None | $2.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H5619-136 (HMO D-SNP)
|
$35.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $2.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H5619-136 (HMO D-SNP)
|
$35.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $2.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H5619-136 (HMO D-SNP)
|
$35.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $2.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 |
Humana Gold Plus SNP-DE H5619-136 (HMO D-SNP)
|
$35.00 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $2.34 |
Browse Plan Formulary all covered insulin pay $35 or less |
Providence Medicare Cottonwood + Rx (HMO-POS)
|
$35.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$10.00 | $10.00 | None | $4.77 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence MedAdvantage + Rx Primary (PPO)
|
$35.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $3.78 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence MedAdvantage + Rx Primary (PPO)
|
$35.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $2.86 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence MedAdvantage + Rx Primary (PPO)
|
$35.00 |
$300 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $4.09 |
Browse Plan Formulary all covered insulin pay $35 or less |
Wellcare Dual Access Open (PPO D-SNP)
|
$36.10 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $9.01 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 |
Community Health Plan of WA MA Plan 2 (HMO)
|
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $20.00 | None | $6.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC WA-0004 (PPO)
|
$39.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $10.42 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Choice Plan (PPO)
|
$39.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $4.03 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Health Plan of WA Dual Complete (HMO D-SNP)
|
$40.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
$0.00 | $0.00 | None | $6.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Health Plan of WA Dual Select (HMO D-SNP)
|
$40.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
1 |
Tier 1 |
15% | 15% | None | $6.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus SNP-DE H5619-155 (HMO D-SNP)
|
$40.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Tier 2 |
$0.00 | $0.00 | None | $2.28 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 |
UHC Care Advantage WA-E001 (PPO I-SNP)
|
$40.60 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Non-Preferred Drug |
$100.00 | $290.00 | None | $10.48 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete WA-D001 (PPO D-SNP)
|
$40.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $10.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete WA-D002 (HMO-POS D-SNP)
|
$40.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $10.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
UHC Dual Complete WA-V001 (HMO-POS D-SNP)
|
$40.60 |
$545 |
No additional gap coverage, only the Donut Hole Discount |
4 |
Tier 4 |
15% | 15% | None | $10.52 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC WA-0005 (HMO-POS)
|
$42.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $10.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
Aetna Medicare Platinum Plus Plan (HMO-POS)
|
$43.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $4.02 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 |
Regence BlueAdvantage HMO Plus (HMO)
|
$46.00 |
$100 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $100.00 | None | $3.45 |
Browse Plan Formulary all covered insulin pay $35 or less |
Premera Blue Cross Medicare Advantage Classic (HMO)
|
$54.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $120.00 | None | $6.08 |
Browse Plan Formulary all covered insulin pay $35 or less |
Humana Gold Plus H5619-059 (HMO)
|
$60.00 |
$0 |
Yes, this drug has Gap Coverage. |
2 |
Generic |
$0.00 | $0.00 | None | $2.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Community Health Plan of WA MA Plan 3 (HMO)
|
$79.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount |
2 |
Generic |
$10.00 | $20.00 | None | $6.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence MedAdvantage + Rx Classic (PPO)
|
$82.00 |
$250 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $100.00 | None | $3.32 |
Browse Plan Formulary all covered insulin pay $35 or less |
AARP Medicare Advantage from UHC WA-0010 (HMO-POS)
|
$84.00 |
$0 |
Yes, but No Gap Coverage for this drug. |
4 |
Non-Preferred Drug |
$95.00 | $275.00 | None | $10.44 |
Browse Plan Formulary all covered insulin pay $35 or less |
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 Select Plan (PPO)
|
$89.00 |
$150 |
Yes, but No Gap Coverage for this drug. |
3 |
Preferred Brand |
$47.00 | $141.00 | P | $4.04 |
Browse Plan Formulary all covered insulin pay $35 or less |
HumanaChoice H5216-047 (PPO)
|
$100.00 |
$320* |
Yes, this drug has Gap Coverage. |
2* |
Generic |
$5.00 | $0.00 | None | $2.30 |
Browse Plan Formulary all covered insulin pay $35 or less |
Regence MedAdvantage + Rx Enhanced (PPO)
|
$147.00 |
$200 |
No additional gap coverage, only the Donut Hole Discount |
3 |
Preferred Brand |
$40.00 | $100.00 | None | $3.23 |
Browse Plan Formulary all covered insulin pay $35 or less |