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 Enhanced w/Std Rx - ND/SD (Cost) in ND - H2450-014-0 Benefit Details |
Barnes | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in ND - H2450-014-0 Benefit Details |
Burleigh | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in ND - H2450-014-0 Benefit Details |
Cass | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in ND - H2450-014-0 Benefit Details |
Cavalier | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in ND - H2450-014-0 Benefit Details |
Dickey | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in ND - H2450-014-0 Benefit Details |
Eddy | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in ND - H2450-014-0 Benefit Details |
Emmons | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in ND - H2450-014-0 Benefit Details |
Foster | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in ND - H2450-014-0 Benefit Details |
Grand Forks | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in ND - H2450-014-0 Benefit Details |
Griggs | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in ND - H2450-014-0 Benefit Details |
Kidder | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in ND - H2450-014-0 Benefit Details |
LaMoure | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in ND - H2450-014-0 Benefit Details |
Logan | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in ND - H2450-014-0 Benefit Details |
McIntosh | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in ND - H2450-014-0 Benefit Details |
Morton | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in ND - H2450-014-0 Benefit Details |
Oliver | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in ND - H2450-014-0 Benefit Details |
Pembina | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in ND - H2450-014-0 Benefit Details |
Ransom | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in ND - H2450-014-0 Benefit Details |
Richland | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in ND - H2450-014-0 Benefit Details |
Sargent | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in ND - H2450-014-0 Benefit Details |
Sioux | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in ND - H2450-014-0 Benefit Details |
Steele | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in ND - H2450-014-0 Benefit Details |
Stutsman | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in ND - H2450-014-0 Benefit Details |
Traill | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in ND - H2450-014-0 Benefit Details |
Walsh | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Aurora | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Beadle | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Bon Homme | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Brookings | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Brown | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Brule | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Buffalo | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Campbell | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Charles Mix | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Clark | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Clay | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Codington | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Davison | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Day | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Deuel | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Douglas | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Edmunds | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Grant | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Gregory | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Hamlin | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Hand | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Hanson | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Hughes | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Hutchinson | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Jerauld | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Kingsbury | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Lake | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Lincoln | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Lyman | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Marshall | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
McCook | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
McPherson | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Miner | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Minnehaha | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Moody | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Roberts | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Sanborn | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Spink | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Stanley | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Tripp | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Turner | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Union | $158.90 | $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 Enhanced w/Std Rx - ND/SD (Cost) in SD - H2450-014-0 Benefit Details |
Yankton | $158.90 | $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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