2010 Medicare Advantage Plan Information Click here to jump to the Chart Legend & Search Tips | |||||||||||
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Plan Name | County | Monthly Prem. (Parts C & D) |
Deduct- ible |
(Donut Hole) Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance 30-Day Supply |
MOOP for Part A & B Benefits | |||||
Cust. Service Rating |
Member Plan Exper. |
RxCost Info Rating |
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Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Barnes | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Burleigh | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Cass | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Cavalier | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Dickey | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Eddy | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Emmons | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Foster | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Grand Forks | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Griggs | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Kidder | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
LaMoure | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Logan | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
McIntosh | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Morton | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Oliver | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Pembina | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Ransom | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Richland | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Sargent | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Sioux | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Steele | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Stutsman | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Traill | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Walsh | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Aurora | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Beadle | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Bon Homme | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Brookings | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Brown | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Brule | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Buffalo | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Campbell | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Charles Mix | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Clark | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Clay | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Codington | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Davison | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Day | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Deuel | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Douglas | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Edmunds | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Grant | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Gregory | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Hamlin | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Hand | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Hanson | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Hughes | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Hutchinson | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Jerauld | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Kingsbury | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Lake | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Lincoln | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Lyman | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Marshall | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
McCook | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
McPherson | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Miner | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Minnehaha | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Moody | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Roberts | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Sanborn | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Spink | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Stanley | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Tripp | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Turner | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Union | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Yankton | $112.90 | $0 | No Gap Coverage | Generic: $10.00 Preferred Brand: $34.00 Non-Preferred Brand: $74.00 Specialty: 25% | n/a Browse Formulary | |||||
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