AMPHETAMINE SALT COMBO 30MG TABLET (100 BOTGL) (NDC: 00185040401)
2015 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 |
AARP MedicareComplete SecureHorizons Plan 1 (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $125.00 | None | $18.82 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 2 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$45.00 | $125.00 | None | $18.82 |
Browse Plan Formulary |
Aetna Medicare Prime Plan (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $135.00 | P Q:60 /30Days | $39.39 |
Browse Plan Formulary |
Aetna Medicare Select Plan (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $135.00 | P Q:60 /30Days | $39.35 |
Browse Plan Formulary |
Blue Cross Senior Secure Plan I (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $120.00 | P Q:60 /30Days | $34.68 |
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 Senior Secure Plan I (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$40.00 | $120.00 | P Q:60 /30Days | $34.08 |
Browse Plan Formulary |
Blue Shield 65 Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$5.00 | $10.00 | Q:60 /30Days | $24.06 |
Browse Plan Formulary |
Bridges Drug Savings (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$9.00 | $25.00 | Q:60 /30Days | $27.56 |
Browse Plan Formulary |
Care1st AdvantageOptimum Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$5.00 | $10.00 | None | $37.52 |
Browse Plan Formulary |
CareMore Breathe (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$7.50 | $18.75 | Q:60 /30Days | $27.24 |
Browse Plan Formulary |
CareMore ESRD (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$7.50 | $18.75 | Q:60 /30Days | $27.24 |
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 |
CareMore Heart (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$7.50 | $18.75 | Q:60 /30Days | $27.24 |
Browse Plan Formulary |
CareMore Reliance (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$7.50 | $18.75 | Q:60 /30Days | $27.24 |
Browse Plan Formulary |
CareMore StartSmart Plus (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$12.50 | $31.25 | Q:60 /30Days | $27.25 |
Browse Plan Formulary |
CareMore Value Plus (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$7.50 | $18.75 | Q:60 /30Days | $27.24 |
Browse Plan Formulary |
Central Health Focus Plan (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$5.00 | $10.00 | None | $27.25 |
Browse Plan Formulary |
Central Health Medicare Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$5.00 | $10.00 | None | $27.25 |
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 |
Citizens Choice Health Plan (HMO)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$5.00 | $10.00 | None | $27.77 |
Browse Plan Formulary |
Classic Care (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$9.00 | $25.00 | Q:60 /30Days | $27.56 |
Browse Plan Formulary |
Easy Choice Best Plan (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$15.00 | $37.50 | P Q:60 /30Days | $37.63 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $32.06 |
Browse Plan Formulary |
Health Net Gold Select (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $31.96 |
Browse Plan Formulary |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $32.32 |
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 |
Health Net Healthy Heart (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $20.00 | None | $32.22 |
Browse Plan Formulary |
Healthy Heart Drug Savings (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$9.00 | $25.00 | Q:60 /30Days | $27.56 |
Browse Plan Formulary |
Heart First (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$12.00 | $24.00 | Q:62 /31Days | $29.22 |
Browse Plan Formulary |
Hope Drug Savings (HMO SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$9.00 | $25.00 | Q:60 /30Days | $27.56 |
Browse Plan Formulary |
Humana Gold Plus H0108-005 (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$30.00 | $60.00 | Q:60 /30Days | $25.19 |
Browse Plan Formulary |
IEHP DualChoice (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic Drugs |
0% | 0% | None | $36.41 |
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 |
In Control Drug Savings (HMO SNP)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$9.00 | $25.00 | Q:60 /30Days | $27.56 |
Browse Plan Formulary |
Inter Valley Health Plan Service To Seniors (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$15.00 | $30.00 | Q:60 /30Days | $27.25 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage B Only South (HMO)
|
$0.00 |
$0 | to be determined | 2 |
Tier 2 |
$12.00 | $24.00 | None | $30.58 |
Browse Plan Formulary |
Kaiser Permanente Senior Advantage Inland Empire (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$12.00 | $24.00 | None | $36.68 |
Browse Plan Formulary |
Molina Dual Options (Medicare-Medicaid Plan)
|
$0.00 |
$0 | No additional gap coverage, only the Donut Hole Discount | 1 |
Generic Drugs |
0% | 0% | Q:60 /30Days | $39.61 |
Browse Plan Formulary |
SCAN Classic (HMO)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$12.00 | $24.00 | Q:62 /31Days | $29.15 |
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 |
SCAN Healthy at Home (HMO SNP)
|
$0.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$10.00 | $20.00 | Q:62 /31Days | $29.32 |
Browse Plan Formulary |
Senior Advantage Medicare Medi-Cal Plan South (HMO SNP)
|
$15.30 |
$0 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$15.00 | $30.00 | None | $30.58 |
Browse Plan Formulary |
Molina Medicare Options Plus (HMO SNP)
|
$21.90 |
$320* | No additional gap coverage, only the Donut Hole Discount | 1* |
Generic |
$0.00 | $0.00 | Q:60 /30Days | $39.60 |
Browse Plan Formulary |
Humana Gold Plus H0108-050 (HMO)
|
$22.90 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Preferred Brand |
$45.00 | $125.00 | Q:60 /30Days | $25.19 |
Browse Plan Formulary |
Care1st TotalDual Plan (HMO SNP)
|
$27.50 |
$320 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
25% | 25% | None | $38.27 |
Browse Plan Formulary |
AARP MedicareComplete SecureHorizons Plan 3 (HMO)
|
$28.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 3 |
Tier 3 |
25% | 25% | None | $19.26 |
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 |
Bridges Extra Care (HMO SNP)
|
$28.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
25% | 25% | Q:60 /30Days | $27.56 |
Browse Plan Formulary |
CalPlus Plan (HMO)
|
$28.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | None | $27.80 |
Browse Plan Formulary |
Central Health Medi-Medi Plan (HMO SNP)
|
$28.80 |
$320* | Yes, but No Gap Coverage for this drug. | 2* |
Non-Preferred Generic |
$0.00 | $0.00 | None | $27.25 |
Browse Plan Formulary |
Central Health Premier Plan (HMO)
|
$28.80 |
$320* | Yes, but No Gap Coverage for this drug. | 2* |
Non-Preferred Generic |
$0.00 | $0.00 | None | $27.25 |
Browse Plan Formulary |
Coordinated Choice Plan (HMO)
|
$28.80 |
$320 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
25% | 25% | None | $35.98 |
Browse Plan Formulary |
Dual Coverage (HMO SNP)
|
$28.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
25% | 25% | Q:60 /30Days | $27.56 |
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 |
Easy Choice Plus Plan (HMO)
|
$28.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$29.00 | $72.50 | P Q:60 /30Days | $37.23 |
Browse Plan Formulary |
Harmony (HMO SNP)
|
$28.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | Q:60 /30Days | $27.56 |
Browse Plan Formulary |
Health Net Seniority Plus Amber I (HMO SNP)
|
$28.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$33.00 | $66.00 | None | $31.98 |
Browse Plan Formulary |
Health Net Seniority Plus Amber II (HMO SNP)
|
$28.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$33.00 | $66.00 | None | $31.97 |
Browse Plan Formulary |
Health Net Seniority Plus Sapphire (HMO)
|
$28.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$30.00 | $60.00 | None | $31.98 |
Browse Plan Formulary |
Healthy Heart Extra Care (HMO SNP)
|
$28.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
25% | 25% | Q:60 /30Days | $27.56 |
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 |
IEHP Medicare DualChoice (HMO SNP)
|
$28.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 1 |
Tier 1 |
$0.00 | $0.00 | None | $36.41 |
Browse Plan Formulary |
In Control Extra Care (HMO SNP)
|
$28.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
25% | 25% | Q:60 /30Days | $27.56 |
Browse Plan Formulary |
SCAN Connections (HMO SNP)
|
$28.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | Q:62 /31Days | $29.31 |
Browse Plan Formulary |
SCAN Connections at Home (HMO SNP)
|
$28.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
$0.00 | $0.00 | Q:62 /31Days | $29.15 |
Browse Plan Formulary |
SCAN Plus (HMO)
|
$28.80 |
$320 | No additional gap coverage, only the Donut Hole Discount | 2 |
Tier 2 |
25% | 25% | Q:62 /31Days | $29.31 |
Browse Plan Formulary |
VillageHealth (HMO-POS SNP)
|
$28.80 |
$310 | No additional gap coverage, only the Donut Hole Discount | 2 |
Non-Preferred Generic |
$18.00 | $54.00 | Q:62 /31Days | $29.22 |
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 |
Humana Gold Plus H0108-006 (HMO)
|
$38.00 |
$0 | Yes, but No Gap Coverage for this drug. | 3 |
Preferred Brand |
$30.00 | $60.00 | Q:60 /30Days | $25.19 |
Browse Plan Formulary |
Health Net Seniority Plus Complete (HMO)
|
$176.00 |
$0 | Yes, but No Gap Coverage for this drug. | 2 |
Non-Preferred Generic |
$15.00 | $30.00 | None | $31.99 |
Browse Plan Formulary |