2010 Medicare Part D Contract ID/Plan ID Search
This is archive material for research purposes. Please see
PDPFinder.com or
MAFinder.com for current plans.
Enter a Contract ID and Plan ID
| 2010 Medicare Advantage Plan Information Click here to jump to the Chart Legend & Search Tips | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 |
|||||||||
|
Sterling Option IV (PFFS) in AL - H5006-016-1 Benefit Details 
 |
Baldwin | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
 |
 |
|
|||||||||
|
Sterling Option IV (PFFS) in AL - H5006-016-1 Benefit Details
|
Bibb | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AL - H5006-016-1 Benefit Details
|
Cherokee | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in AL - H5006-016-1 Benefit Details
|
Clarke | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AL - H5006-016-1 Benefit Details
|
Conecuh | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AL - H5006-016-1 Benefit Details
|
Covington | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in AL - H5006-016-1 Benefit Details
|
DeKalb | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AL - H5006-016-1 Benefit Details
|
Escambia | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AL - H5006-016-1 Benefit Details
|
Etowah | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in AL - H5006-016-1 Benefit Details
|
Jackson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AL - H5006-016-1 Benefit Details
|
Jefferson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AL - H5006-016-1 Benefit Details
|
Limestone | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in AL - H5006-016-1 Benefit Details
|
Madison | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AL - H5006-016-1 Benefit Details
|
Marshall | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AL - H5006-016-1 Benefit Details
|
Mobile | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in AL - H5006-016-1 Benefit Details
|
Monroe | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AL - H5006-016-1 Benefit Details
|
Morgan | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AL - H5006-016-1 Benefit Details
|
Shelby | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in AL - H5006-016-1 Benefit Details
|
Tuscaloosa | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AL - H5006-016-1 Benefit Details
|
Walker | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AL - H5006-016-1 Benefit Details
|
Washington | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-2 Benefit Details
|
Arkansas | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-1 Benefit Details
|
Benton | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-2 Benefit Details
|
Boone | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-2 Benefit Details
|
Carroll | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-2 Benefit Details
|
Cleburne | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-2 Benefit Details
|
Conway | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-1 Benefit Details
|
Craighead | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-1 Benefit Details
|
Crawford | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-1 Benefit Details
|
Crittenden | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-2 Benefit Details
|
Cross | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-1 Benefit Details
|
Faulkner | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-1 Benefit Details
|
Franklin | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-1 Benefit Details
|
Garland | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-1 Benefit Details
|
Grant | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-2 Benefit Details
|
Hot Spring | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-1 Benefit Details
|
Jefferson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-2 Benefit Details
|
Johnson | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-2 Benefit Details
|
Lee | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-2 Benefit Details
|
Logan | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-1 Benefit Details
|
Lonoke | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-1 Benefit Details
|
Madison | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-2 Benefit Details
|
Marion | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-2 Benefit Details
|
Mississippi | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-2 Benefit Details
|
Newton | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-1 Benefit Details
|
Perry | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-1 Benefit Details
|
Poinsett | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-2 Benefit Details
|
Pope | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-2 Benefit Details
|
Prairie | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-1 Benefit Details
|
Pulaski | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-1 Benefit Details
|
Saline | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-2 Benefit Details
|
Scott | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-1 Benefit Details
|
Sebastian | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-2 Benefit Details
|
St. Francis | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-2 Benefit Details
|
Van Buren | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-1 Benefit Details
|
Washington | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-2 Benefit Details
|
White | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in AR - H5006-016-2 Benefit Details
|
Yell | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in CA - H5006-016-3 Benefit Details
|
Alameda | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in CA - H5006-016-3 Benefit Details
|
Alpine | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in CA - H5006-016-3 Benefit Details
|
Amador | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in CA - H5006-016-3 Benefit Details
|
Calaveras | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in CA - H5006-016-3 Benefit Details
|
Colusa | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in CA - H5006-016-3 Benefit Details
|
Contra Costa | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in CA - H5006-016-3 Benefit Details
|
El Dorado | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in CA - H5006-016-3 Benefit Details
|
Fresno | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in CA - H5006-016-3 Benefit Details
|
Lake | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in CA - H5006-016-3 Benefit Details
|
Madera | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in CA - H5006-016-3 Benefit Details
|
Mendocino | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in CA - H5006-016-3 Benefit Details
|
Napa | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in CA - H5006-016-3 Benefit Details
|
Placer | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in CA - H5006-016-3 Benefit Details
|
Sacramento | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in CA - H5006-016-3 Benefit Details
|
San Luis Obispo | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in CA - H5006-016-3 Benefit Details
|
Santa Barbara | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in CA - H5006-016-3 Benefit Details
|
Solano | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in CA - H5006-016-3 Benefit Details
|
Sonoma | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in CA - H5006-016-3 Benefit Details
|
Tulare | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in CA - H5006-016-3 Benefit Details
|
Yolo | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in CO - H5006-016-3 Benefit Details
|
Adams | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in CO - H5006-016-3 Benefit Details
|
Arapahoe | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in CO - H5006-016-1 Benefit Details
|
Boulder | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in CO - H5006-016-3 Benefit Details
|
Broomfield | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in CO - H5006-016-3 Benefit Details
|
Clear Creek | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in CO - H5006-016-3 Benefit Details
|
Denver | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in CO - H5006-016-3 Benefit Details
|
Douglas | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in CO - H5006-016-1 Benefit Details
|
El Paso | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in CO - H5006-016-3 Benefit Details
|
Elbert | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in CO - H5006-016-3 Benefit Details
|
Gilpin | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in CO - H5006-016-3 Benefit Details
|
Jefferson | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in CO - H5006-016-1 Benefit Details
|
Larimer | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in CO - H5006-016-3 Benefit Details
|
Park | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in CO - H5006-016-1 Benefit Details
|
Pueblo | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in CO - H5006-016-1 Benefit Details
|
Teller | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in CO - H5006-016-1 Benefit Details
|
Weld | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in DE - H5006-016-3 Benefit Details
|
Kent | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in DE - H5006-016-3 Benefit Details
|
New Castle | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in DE - H5006-016-3 Benefit Details
|
Sussex | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in FL - H5006-016-1 Benefit Details
|
Escambia | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in FL - H5006-016-1 Benefit Details
|
Okaloosa | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in FL - H5006-016-1 Benefit Details
|
Santa Rosa | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-3 Benefit Details
|
Bartow | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-1 Benefit Details
|
Bryan | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-2 Benefit Details
|
Bulloch | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-1 Benefit Details
|
Burke | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-1 Benefit Details
|
Catoosa | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-1 Benefit Details
|
Chatham | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-1 Benefit Details
|
Chattahoochee | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-3 Benefit Details
|
Cherokee | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-3 Benefit Details
|
Clayton | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-3 Benefit Details
|
Cobb | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-1 Benefit Details
|
Columbia | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-3 Benefit Details
|
Coweta | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-1 Benefit Details
|
Dade | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-3 Benefit Details
|
Dawson | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-3 Benefit Details
|
DeKalb | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-3 Benefit Details
|
Douglas | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-1 Benefit Details
|
Effingham | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-2 Benefit Details
|
Evans | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-3 Benefit Details
|
Fayette | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-3 Benefit Details
|
Forsyth | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-3 Benefit Details
|
Fulton | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-2 Benefit Details
|
Glascock | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-3 Benefit Details
|
Gordon | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-3 Benefit Details
|
Gwinnett | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-1 Benefit Details
|
Hall | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-1 Benefit Details
|
Harris | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-3 Benefit Details
|
Henry | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-2 Benefit Details
|
Jefferson | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-1 Benefit Details
|
Liberty | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-2 Benefit Details
|
Lincoln | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-1 Benefit Details
|
Marion | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-1 Benefit Details
|
McDuffie | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-1 Benefit Details
|
Muscogee | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-3 Benefit Details
|
Newton | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-3 Benefit Details
|
Paulding | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-3 Benefit Details
|
Pickens | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-1 Benefit Details
|
Richmond | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-3 Benefit Details
|
Rockdale | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-2 Benefit Details
|
Screven | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-2 Benefit Details
|
Stewart | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-2 Benefit Details
|
Taliaferro | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-1 Benefit Details
|
Walker | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-3 Benefit Details
|
Walton | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-2 Benefit Details
|
Warren | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-1 Benefit Details
|
Whitfield | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in GA - H5006-016-2 Benefit Details
|
Wilkes | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Ada | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Adams | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Bannock | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Bear Lake | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Benewah | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Bingham | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Blaine | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Boise | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Bonner | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Bonneville | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Boundary | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Butte | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Camas | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Canyon | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Caribou | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Cassia | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Clark | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Clearwater | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Custer | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Elmore | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Franklin | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Fremont | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Gem | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Gooding | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Idaho | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Jefferson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Jerome | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Kootenai | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Latah | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Lemhi | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Lewis | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Lincoln | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Madison | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Minidoka | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Nez Perce | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Oneida | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Owyhee | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Payette | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Power | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Shoshone | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Teton | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Twin Falls | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Valley | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in ID - H5006-016-1 Benefit Details
|
Washington | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Bond | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Boone | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Calhoun | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Champaign | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Clinton | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
De Witt | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Ford | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Fulton | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Greene | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Henry | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Jersey | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Kankakee | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Knox | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Livingston | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Logan | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Macoupin | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-1 Benefit Details
|
Madison | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Marshall | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Mason | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-1 Benefit Details
|
McLean | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Mercer | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Monroe | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Montgomery | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Ogle | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-1 Benefit Details
|
Peoria | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Piatt | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Randolph | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Rock Island | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-1 Benefit Details
|
St. Clair | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Stark | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Stephenson | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-1 Benefit Details
|
Tazewell | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Vermilion | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Wabash | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Washington | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
White | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Whiteside | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-2 Benefit Details
|
Winnebago | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IL - H5006-016-1 Benefit Details
|
Woodford | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-3 Benefit Details
|
Adams | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-2 Benefit Details
|
Allen | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-3 Benefit Details
|
Boone | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-1 Benefit Details
|
Clark | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-3 Benefit Details
|
De Kalb | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-3 Benefit Details
|
Delaware | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-3 Benefit Details
|
Dubois | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-3 Benefit Details
|
Elkhart | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-1 Benefit Details
|
Floyd | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-3 Benefit Details
|
Fulton | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-1 Benefit Details
|
Gibson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-3 Benefit Details
|
Hamilton | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-3 Benefit Details
|
Hancock | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-1 Benefit Details
|
Harrison | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-3 Benefit Details
|
Hendricks | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-3 Benefit Details
|
Henry | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-3 Benefit Details
|
Huntington | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-3 Benefit Details
|
Johnson | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-3 Benefit Details
|
Kosciusko | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-3 Benefit Details
|
La Porte | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-3 Benefit Details
|
Lagrange | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-3 Benefit Details
|
Madison | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-3 Benefit Details
|
Marion | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-3 Benefit Details
|
Marshall | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-3 Benefit Details
|
Miami | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-3 Benefit Details
|
Morgan | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-3 Benefit Details
|
Noble | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-3 Benefit Details
|
Pike | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-1 Benefit Details
|
Posey | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-3 Benefit Details
|
Rush | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-3 Benefit Details
|
Shelby | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-3 Benefit Details
|
Spencer | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-2 Benefit Details
|
St. Joseph | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-3 Benefit Details
|
Starke | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-3 Benefit Details
|
Steuben | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-1 Benefit Details
|
Vanderburgh | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-3 Benefit Details
|
Wabash | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-1 Benefit Details
|
Warrick | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-2 Benefit Details
|
Wells | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IN - H5006-016-2 Benefit Details
|
Whitley | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Adair | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Adams | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Allamakee | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Appanoose | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Audubon | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Benton | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Black Hawk | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Boone | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Bremer | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Buchanan | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Buena Vista | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Butler | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Calhoun | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Carroll | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Cass | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Cedar | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Cerro Gordo | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Cherokee | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Chickasaw | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Clarke | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Clay | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Clayton | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Clinton | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Crawford | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Dallas | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Davis | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Decatur | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Delaware | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Des Moines | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Dickinson | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Dubuque | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Emmet | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Fayette | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Floyd | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Franklin | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Fremont | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Greene | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Grundy | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Guthrie | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Hamilton | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Hancock | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Hardin | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Harrison | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Henry | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Howard | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Humboldt | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Ida | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Iowa | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Jackson | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Jasper | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Jefferson | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Johnson | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Jones | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Keokuk | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Kossuth | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Lee | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Linn | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Louisa | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Lucas | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Lyon | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Madison | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Mahaska | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Marion | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Marshall | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Mills | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Mitchell | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Monona | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Monroe | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Montgomery | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Muscatine | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
O'Brien | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Osceola | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Page | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Palo Alto | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Plymouth | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Pocahontas | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Polk | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Pottawattamie | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Poweshiek | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Ringgold | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Sac | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Scott | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Shelby | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Sioux | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Story | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Tama | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Taylor | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Union | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Van Buren | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Wapello | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Warren | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Washington | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Wayne | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Webster | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Winnebago | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Winneshiek | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Woodbury | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Worth | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in IA - H5006-016-2 Benefit Details
|
Wright | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KS - H5006-016-3 Benefit Details
|
Atchison | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KS - H5006-016-3 Benefit Details
|
Butler | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KS - H5006-016-3 Benefit Details
|
Doniphan | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KS - H5006-016-3 Benefit Details
|
Douglas | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KS - H5006-016-3 Benefit Details
|
Franklin | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KS - H5006-016-3 Benefit Details
|
Harvey | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KS - H5006-016-3 Benefit Details
|
Jackson | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KS - H5006-016-3 Benefit Details
|
Jefferson | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KS - H5006-016-3 Benefit Details
|
Johnson | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KS - H5006-016-3 Benefit Details
|
Leavenworth | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KS - H5006-016-3 Benefit Details
|
Miami | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KS - H5006-016-3 Benefit Details
|
Osage | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KS - H5006-016-3 Benefit Details
|
Sedgwick | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KS - H5006-016-3 Benefit Details
|
Shawnee | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KS - H5006-016-3 Benefit Details
|
Sumner | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KS - H5006-016-3 Benefit Details
|
Wyandotte | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Adair | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Allen | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Anderson | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Ballard | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Barren | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Bath | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Bell | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Boone | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-1 Benefit Details
|
Bourbon | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-1 Benefit Details
|
Boyd | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Boyle | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Bracken | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Breathitt | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Breckinridge | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-1 Benefit Details
|
Bullitt | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Butler | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Caldwell | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Calloway | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Campbell | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Carlisle | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Carroll | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Carter | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Casey | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-1 Benefit Details
|
Christian | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-1 Benefit Details
|
Clark | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Clay | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Clinton | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Crittenden | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Cumberland | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-1 Benefit Details
|
Daviess | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Edmonson | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Elliott | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Estill | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-1 Benefit Details
|
Fayette | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Fleming | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Floyd | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Franklin | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Fulton | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Gallatin | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Garrard | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Grant | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Graves | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Grayson | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Green | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-1 Benefit Details
|
Greenup | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-1 Benefit Details
|
Hancock | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-1 Benefit Details
|
Hardin | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Harlan | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Harrison | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Hart | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-1 Benefit Details
|
Henderson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-1 Benefit Details
|
Henry | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Hickman | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Hopkins | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Jackson | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-1 Benefit Details
|
Jefferson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-1 Benefit Details
|
Jessamine | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Johnson | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Kenton | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Knott | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Knox | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-1 Benefit Details
|
Larue | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Laurel | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Lawrence | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Lee | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Leslie | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Letcher | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Lewis | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Lincoln | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Livingston | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Logan | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Lyon | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Madison | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Magoffin | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Marion | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Marshall | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Martin | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Mason | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
McCracken | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
McCreary | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-1 Benefit Details
|
McLean | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-1 Benefit Details
|
Meade | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Menifee | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Mercer | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Metcalfe | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Monroe | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Montgomery | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Morgan | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Muhlenberg | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-1 Benefit Details
|
Nelson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Nicholas | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Ohio | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-1 Benefit Details
|
Oldham | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Owen | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Owsley | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Pendleton | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Perry | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Pike | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Powell | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Pulaski | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Robertson | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Rockcastle | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Rowan | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Russell | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-1 Benefit Details
|
Scott | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-1 Benefit Details
|
Shelby | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Simpson | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-1 Benefit Details
|
Spencer | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Taylor | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Todd | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-1 Benefit Details
|
Trigg | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-1 Benefit Details
|
Trimble | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Union | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Warren | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Washington | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Wayne | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-1 Benefit Details
|
Webster | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Whitley | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-3 Benefit Details
|
Wolfe | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in KY - H5006-016-1 Benefit Details
|
Woodford | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Acadia | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Allen | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Ascension | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Assumption | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Avoyelles | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Beauregard | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Bienville | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Bossier | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Caddo | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Calcasieu | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Caldwell | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Cameron | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Catahoula | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Claiborne | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Concordia | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
De Soto | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
East Baton Rouge | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
East Carroll | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
East Feliciana | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Evangeline | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Franklin | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Grant | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Iberia | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Iberville | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Jackson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Jefferson Davis | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
La Salle | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Lafayette | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Lincoln | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Livingston | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Madison | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Morehouse | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Natchitoches | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Ouachita | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Pointe Coupee | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Rapides | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Red River | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Richland | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Sabine | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
St. Helena | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
St. Landry | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
St. Martin | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
St. Mary | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Tangipahoa | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Tensas | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Union | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Vermilion | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Vernon | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Washington | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Webster | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
West Baton Rouge | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
West Carroll | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
West Feliciana | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in LA - H5006-016-1 Benefit Details
|
Winn | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MI - H5006-016-2 Benefit Details
|
Allegan | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MI - H5006-016-2 Benefit Details
|
Barry | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MI - H5006-016-2 Benefit Details
|
Ionia | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MI - H5006-016-2 Benefit Details
|
Kent | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MI - H5006-016-2 Benefit Details
|
Muskegon | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MI - H5006-016-2 Benefit Details
|
Ottawa | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Aitkin | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-1 Benefit Details
|
Anoka | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Becker | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Beltrami | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Benton | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Big Stone | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Blue Earth | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Brown | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Carlton | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-1 Benefit Details
|
Carver | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Cass | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Chippewa | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-1 Benefit Details
|
Chisago | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Clay | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Clearwater | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Cook | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Cottonwood | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Crow Wing | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-1 Benefit Details
|
Dakota | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Dodge | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Douglas | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Faribault | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Fillmore | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Freeborn | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Goodhue | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Grant | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-1 Benefit Details
|
Hennepin | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Houston | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Hubbard | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-1 Benefit Details
|
Isanti | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Itasca | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Jackson | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Kanabec | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Kandiyohi | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Kittson | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Koochiching | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Lac qui Parle | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Lake | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Lake of the Woods | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Le Sueur | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Lincoln | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Lyon | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Mahnomen | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Marshall | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Martin | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
McLeod | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Meeker | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Mille Lacs | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Morrison | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Mower | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Murray | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Nicollet | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Nobles | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Norman | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Olmsted | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Otter Tail | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Pennington | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Pine | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Pipestone | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Polk | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Pope | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-1 Benefit Details
|
Ramsey | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Red Lake | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Redwood | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Renville | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Rice | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Rock | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Roseau | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-1 Benefit Details
|
Scott | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-1 Benefit Details
|
Sherburne | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Sibley | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
St. Louis | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Stearns | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Steele | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Stevens | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Swift | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Todd | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Traverse | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Wabasha | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Wadena | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Waseca | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-1 Benefit Details
|
Washington | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Watonwan | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Wilkin | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Winona | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-1 Benefit Details
|
Wright | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MN - H5006-016-2 Benefit Details
|
Yellow Medicine | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-3 Benefit Details
|
Bates | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-1 Benefit Details
|
Boone | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-3 Benefit Details
|
Buchanan | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-3 Benefit Details
|
Callaway | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-3 Benefit Details
|
Cass | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-1 Benefit Details
|
Christian | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-3 Benefit Details
|
Clay | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-3 Benefit Details
|
Clinton | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-1 Benefit Details
|
Cole | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-1 Benefit Details
|
Crawford | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-1 Benefit Details
|
Dallas | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-3 Benefit Details
|
Douglas | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-1 Benefit Details
|
Franklin | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-3 Benefit Details
|
Gasconade | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-1 Benefit Details
|
Greene | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-3 Benefit Details
|
Henry | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-1 Benefit Details
|
Howard | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-3 Benefit Details
|
Iron | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-3 Benefit Details
|
Jackson | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-1 Benefit Details
|
Jefferson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-3 Benefit Details
|
Johnson | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-3 Benefit Details
|
Laclede | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-3 Benefit Details
|
Lafayette | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-1 Benefit Details
|
Lincoln | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-1 Benefit Details
|
Moniteau | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-3 Benefit Details
|
Montgomery | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-1 Benefit Details
|
Osage | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-3 Benefit Details
|
Pike | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-3 Benefit Details
|
Platte | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-1 Benefit Details
|
Polk | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-1 Benefit Details
|
Randolph | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-3 Benefit Details
|
Ray | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-1 Benefit Details
|
St. Charles | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-3 Benefit Details
|
St. Francois | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-1 Benefit Details
|
St. Louis | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-1 Benefit Details
|
St. Louis City | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-3 Benefit Details
|
Ste. Genevieve | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-1 Benefit Details
|
Warren | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-1 Benefit Details
|
Washington | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-1 Benefit Details
|
Webster | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MO - H5006-016-3 Benefit Details
|
Wright | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Beaverhead | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Big Horn | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Blaine | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Broadwater | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Carbon | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Carter | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Cascade | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Chouteau | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Custer | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Daniels | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Dawson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Deer Lodge | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Fallon | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Fergus | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Flathead | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Gallatin | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Garfield | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Glacier | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Golden Valley | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Granite | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Hill | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Jefferson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Judith Basin | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Lake | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Lewis and Clark | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Liberty | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Lincoln | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Madison | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
McCone | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Meagher | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Mineral | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Missoula | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Musselshell | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Park | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Petroleum | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Phillips | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Pondera | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Powder River | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Powell | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Prairie | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Ravalli | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Richland | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Roosevelt | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Rosebud | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Sanders | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Sheridan | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Silver Bow | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Stillwater | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Sweet Grass | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Teton | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Toole | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Treasure | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Valley | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Wheatland | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Wibaux | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in MT - H5006-016-1 Benefit Details
|
Yellowstone | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Adams | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Antelope | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Arthur | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Banner | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Blaine | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Boone | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Box Butte | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Boyd | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Brown | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Buffalo | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Burt | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Butler | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Cass | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Cedar | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Chase | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Cherry | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Cheyenne | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Clay | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Colfax | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Cuming | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Custer | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Dakota | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Dawes | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Dawson | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Deuel | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Dixon | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Dodge | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Douglas | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Dundy | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Fillmore | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Franklin | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Frontier | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Furnas | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Gage | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Garden | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Garfield | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Gosper | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Grant | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Greeley | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Hall | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Hamilton | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Harlan | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Hayes | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Hitchcock | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Holt | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Hooker | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Howard | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Jefferson | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Johnson | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Kearney | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Keith | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Keya Paha | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Kimball | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Knox | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Lancaster | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Lincoln | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Logan | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Loup | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Madison | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
McPherson | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Merrick | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Morrill | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Nance | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Nemaha | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Nuckolls | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Otoe | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Pawnee | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Perkins | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Phelps | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Pierce | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Platte | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Polk | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Red Willow | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Richardson | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Rock | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Saline | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Sarpy | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Saunders | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Scotts Bluff | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Seward | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Sheridan | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Sherman | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Sioux | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Stanton | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Thayer | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Thomas | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Thurston | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Valley | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Washington | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Wayne | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Webster | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
Wheeler | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NE - H5006-016-2 Benefit Details
|
York | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NV - H5006-016-1 Benefit Details
|
Carson City | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NV - H5006-016-2 Benefit Details
|
Clark | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NV - H5006-016-1 Benefit Details
|
Douglas | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NV - H5006-016-1 Benefit Details
|
Lincoln | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NV - H5006-016-1 Benefit Details
|
Lyon | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NV - H5006-016-1 Benefit Details
|
Storey | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NV - H5006-016-1 Benefit Details
|
Washoe | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NJ - H5006-016-2 Benefit Details
|
Atlantic | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NJ - H5006-016-2 Benefit Details
|
Cape May | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NJ - H5006-016-2 Benefit Details
|
Cumberland | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NJ - H5006-016-2 Benefit Details
|
Middlesex | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NJ - H5006-016-2 Benefit Details
|
Monmouth | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NJ - H5006-016-2 Benefit Details
|
Ocean | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NJ - H5006-016-2 Benefit Details
|
Salem | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
Bernalillo | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
Catron | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
Chaves | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
Cibola | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
Colfax | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
Curry | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
DeBaca | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
Dona Ana | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
Eddy | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
Grant | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
Guadalupe | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
Harding | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
Hidalgo | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
Lea | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
Lincoln | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
Los Alamos | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
Luna | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
McKinley | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
Mora | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
Otero | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
Quay | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
Rio Arriba | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
Roosevelt | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
San Juan | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
San Miguel | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
Sandoval | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
Santa Fe | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
Sierra | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
Socorro | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
Taos | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
Torrance | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
Union | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NM - H5006-016-1 Benefit Details
|
Valencia | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-2 Benefit Details
|
Albany | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Allegany | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Bronx | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-2 Benefit Details
|
Broome | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Cattaraugus | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-2 Benefit Details
|
Cayuga | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Chautauqua | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-2 Benefit Details
|
Chemung | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Chenango | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Clinton | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Columbia | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Cortland | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Delaware | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Dutchess | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-2 Benefit Details
|
Erie | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Essex | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Franklin | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Fulton | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Genesee | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Greene | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Hamilton | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-2 Benefit Details
|
Herkimer | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Jefferson | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Kings | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Lewis | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-2 Benefit Details
|
Livingston | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-2 Benefit Details
|
Madison | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-2 Benefit Details
|
Monroe | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-2 Benefit Details
|
Montgomery | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Nassau | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
New York | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-2 Benefit Details
|
Niagara | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-2 Benefit Details
|
Oneida | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-2 Benefit Details
|
Onondaga | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-2 Benefit Details
|
Ontario | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Orange | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-2 Benefit Details
|
Orleans | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-2 Benefit Details
|
Oswego | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Otsego | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Putnam | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Queens | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-2 Benefit Details
|
Rensselaer | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Richmond | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Rockland | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-2 Benefit Details
|
Saratoga | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-2 Benefit Details
|
Schenectady | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-2 Benefit Details
|
Schoharie | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Schuyler | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Seneca | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
St. Lawrence | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Steuben | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Suffolk | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Sullivan | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-2 Benefit Details
|
Tioga | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Tompkins | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Ulster | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-2 Benefit Details
|
Warren | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-2 Benefit Details
|
Washington | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-2 Benefit Details
|
Wayne | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Westchester | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Wyoming | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NY - H5006-016-3 Benefit Details
|
Yates | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-1 Benefit Details
|
Alamance | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-1 Benefit Details
|
Anson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-3 Benefit Details
|
Ashe | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-3 Benefit Details
|
Avery | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-1 Benefit Details
|
Buncombe | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-1 Benefit Details
|
Cabarrus | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-1 Benefit Details
|
Chatham | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-1 Benefit Details
|
Cumberland | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-3 Benefit Details
|
Davidson | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-1 Benefit Details
|
Davie | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-1 Benefit Details
|
Durham | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-1 Benefit Details
|
Forsyth | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-1 Benefit Details
|
Franklin | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-1 Benefit Details
|
Gaston | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-3 Benefit Details
|
Granville | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-1 Benefit Details
|
Guilford | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-3 Benefit Details
|
Harnett | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-1 Benefit Details
|
Henderson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-1 Benefit Details
|
Johnston | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-3 Benefit Details
|
Lincoln | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-1 Benefit Details
|
Mecklenburg | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-1 Benefit Details
|
Orange | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-1 Benefit Details
|
Person | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-3 Benefit Details
|
Polk | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-1 Benefit Details
|
Randolph | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-1 Benefit Details
|
Rockingham | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-3 Benefit Details
|
Stanly | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-1 Benefit Details
|
Stokes | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-3 Benefit Details
|
Surry | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-3 Benefit Details
|
Transylvania | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-1 Benefit Details
|
Union | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-1 Benefit Details
|
Wake | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-3 Benefit Details
|
Watauga | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in NC - H5006-016-1 Benefit Details
|
Yadkin | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in ND - H5006-016-2 Benefit Details
|
Barnes | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ND - H5006-016-2 Benefit Details
|
Benson | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ND - H5006-016-2 Benefit Details
|
Cass | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in ND - H5006-016-2 Benefit Details
|
Cavalier | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ND - H5006-016-2 Benefit Details
|
Dickey | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ND - H5006-016-2 Benefit Details
|
Eddy | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in ND - H5006-016-2 Benefit Details
|
Foster | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ND - H5006-016-2 Benefit Details
|
Grand Forks | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ND - H5006-016-2 Benefit Details
|
Griggs | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in ND - H5006-016-2 Benefit Details
|
LaMoure | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ND - H5006-016-2 Benefit Details
|
Nelson | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ND - H5006-016-2 Benefit Details
|
Pembina | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in ND - H5006-016-2 Benefit Details
|
Ramsey | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ND - H5006-016-2 Benefit Details
|
Ransom | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ND - H5006-016-2 Benefit Details
|
Richland | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in ND - H5006-016-2 Benefit Details
|
Sargent | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ND - H5006-016-2 Benefit Details
|
Steele | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ND - H5006-016-2 Benefit Details
|
Stutsman | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in ND - H5006-016-2 Benefit Details
|
Towner | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ND - H5006-016-2 Benefit Details
|
Traill | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in ND - H5006-016-2 Benefit Details
|
Walsh | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in OH - H5006-016-3 Benefit Details
|
Defiance | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OH - H5006-016-3 Benefit Details
|
Erie | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OH - H5006-016-3 Benefit Details
|
Fulton | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in OH - H5006-016-3 Benefit Details
|
Henry | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OH - H5006-016-3 Benefit Details
|
Ottawa | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OH - H5006-016-3 Benefit Details
|
Paulding | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in OH - H5006-016-3 Benefit Details
|
Putnam | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OH - H5006-016-3 Benefit Details
|
Sandusky | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OH - H5006-016-3 Benefit Details
|
Van Wert | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in OH - H5006-016-3 Benefit Details
|
Williams | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OH - H5006-016-3 Benefit Details
|
Wood | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Adair | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Atoka | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Blaine | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Caddo | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Canadian | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Cherokee | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Choctaw | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Cleveland | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Comanche | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Craig | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-1 Benefit Details
|
Creek | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Custer | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Delaware | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Garvin | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Grady | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Haskell | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Hughes | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Kingfisher | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Kiowa | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Latimer | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-1 Benefit Details
|
Le Flore | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-1 Benefit Details
|
Lincoln | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-1 Benefit Details
|
Logan | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Mayes | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
McClain | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
McCurtain | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
McIntosh | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Murray | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Muskogee | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Noble | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Nowata | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Okfuskee | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-1 Benefit Details
|
Oklahoma | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-1 Benefit Details
|
Okmulgee | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Ottawa | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-1 Benefit Details
|
Pawnee | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Payne | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Pittsburg | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Pottawatomie | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Pushmataha | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-1 Benefit Details
|
Rogers | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Seminole | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-1 Benefit Details
|
Sequoyah | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-1 Benefit Details
|
Tulsa | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-1 Benefit Details
|
Wagoner | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Washington | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in OK - H5006-016-2 Benefit Details
|
Washita | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OR - H5006-016-2 Benefit Details
|
Benton | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OR - H5006-016-1 Benefit Details
|
Clackamas | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in OR - H5006-016-2 Benefit Details
|
Clatsop | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OR - H5006-016-1 Benefit Details
|
Columbia | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OR - H5006-016-2 Benefit Details
|
Coos | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in OR - H5006-016-2 Benefit Details
|
Curry | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OR - H5006-016-2 Benefit Details
|
Deschutes | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OR - H5006-016-2 Benefit Details
|
Douglas | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in OR - H5006-016-2 Benefit Details
|
Hood River | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OR - H5006-016-2 Benefit Details
|
Jackson | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OR - H5006-016-2 Benefit Details
|
Josephine | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in OR - H5006-016-2 Benefit Details
|
Klamath | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OR - H5006-016-2 Benefit Details
|
Lake | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OR - H5006-016-1 Benefit Details
|
Lane | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in OR - H5006-016-2 Benefit Details
|
Lincoln | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OR - H5006-016-2 Benefit Details
|
Linn | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OR - H5006-016-2 Benefit Details
|
Marion | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in OR - H5006-016-2 Benefit Details
|
Morrow | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OR - H5006-016-1 Benefit Details
|
Multnomah | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OR - H5006-016-2 Benefit Details
|
Polk | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in OR - H5006-016-2 Benefit Details
|
Tillamook | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OR - H5006-016-2 Benefit Details
|
Umatilla | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OR - H5006-016-2 Benefit Details
|
Union | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in OR - H5006-016-2 Benefit Details
|
Wallowa | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OR - H5006-016-1 Benefit Details
|
Washington | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in OR - H5006-016-1 Benefit Details
|
Yamhill | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Adams | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-2 Benefit Details
|
Allegheny | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-2 Benefit Details
|
Armstrong | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-2 Benefit Details
|
Beaver | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Bedford | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Berks | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Blair | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Bradford | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-2 Benefit Details
|
Bucks | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-2 Benefit Details
|
Butler | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Cambria | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Cameron | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Carbon | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Centre | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-2 Benefit Details
|
Chester | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Clarion | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Clearfield | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Clinton | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Columbia | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Crawford | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Cumberland | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Dauphin | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-2 Benefit Details
|
Delaware | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Elk | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Erie | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-2 Benefit Details
|
Fayette | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Forest | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Franklin | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Fulton | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Greene | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Huntingdon | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Indiana | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Jefferson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Juniata | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Lackawanna | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Lancaster | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Lawrence | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Lebanon | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Lehigh | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Luzerne | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Lycoming | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
McKean | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Mercer | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Mifflin | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Monroe | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-2 Benefit Details
|
Montgomery | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Montour | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Northampton | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Northumberland | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Perry | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-2 Benefit Details
|
Philadelphia | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Pike | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Potter | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Schuylkill | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Snyder | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Somerset | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Sullivan | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Susquehanna | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Tioga | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Union | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Venango | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Warren | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-2 Benefit Details
|
Washington | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Wayne | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-2 Benefit Details
|
Westmoreland | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
Wyoming | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in PA - H5006-016-1 Benefit Details
|
York | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SC - H5006-016-1 Benefit Details
|
Aiken | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SC - H5006-016-1 Benefit Details
|
Anderson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SC - H5006-016-1 Benefit Details
|
Beaufort | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SC - H5006-016-1 Benefit Details
|
Berkeley | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SC - H5006-016-1 Benefit Details
|
Calhoun | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SC - H5006-016-1 Benefit Details
|
Charleston | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SC - H5006-016-1 Benefit Details
|
Cherokee | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SC - H5006-016-1 Benefit Details
|
Colleton | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SC - H5006-016-1 Benefit Details
|
Dorchester | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SC - H5006-016-1 Benefit Details
|
Edgefield | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SC - H5006-016-1 Benefit Details
|
Fairfield | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SC - H5006-016-1 Benefit Details
|
Florence | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SC - H5006-016-1 Benefit Details
|
Georgetown | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SC - H5006-016-1 Benefit Details
|
Greenville | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SC - H5006-016-1 Benefit Details
|
Horry | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SC - H5006-016-1 Benefit Details
|
Jasper | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SC - H5006-016-1 Benefit Details
|
Kershaw | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SC - H5006-016-1 Benefit Details
|
Laurens | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SC - H5006-016-1 Benefit Details
|
Lexington | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SC - H5006-016-1 Benefit Details
|
Marion | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SC - H5006-016-1 Benefit Details
|
Oconee | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SC - H5006-016-1 Benefit Details
|
Pickens | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SC - H5006-016-1 Benefit Details
|
Richland | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SC - H5006-016-1 Benefit Details
|
Saluda | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SC - H5006-016-1 Benefit Details
|
Spartanburg | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SC - H5006-016-1 Benefit Details
|
Union | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SC - H5006-016-1 Benefit Details
|
Williamsburg | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SC - H5006-016-1 Benefit Details
|
York | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Aurora | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Beadle | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Bennett | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Bon Homme | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Brookings | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Brown | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Brule | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Buffalo | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Butte | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Campbell | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Charles Mix | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Clark | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Clay | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Codington | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Corson | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Custer | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Davison | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Day | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Deuel | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Dewey | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Douglas | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Edmunds | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Fall River | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Faulk | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Grant | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Gregory | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Haakon | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Hamlin | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Hand | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Hanson | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Harding | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Hughes | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Hutchinson | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Hyde | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Jackson | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Jerauld | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Jones | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Kingsbury | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Lake | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Lawrence | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Lincoln | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Lyman | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Marshall | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
McCook | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
McPherson | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Meade | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Mellette | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Miner | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Minnehaha | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Moody | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Pennington | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Perkins | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Potter | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Roberts | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Sanborn | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Shannon | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Spink | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Stanley | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Sully | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Todd | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Tripp | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Turner | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Union | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Walworth | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Washabaugh | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Yankton | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in SD - H5006-016-2 Benefit Details
|
Ziebach | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-1 Benefit Details
|
Anderson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Bedford | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Benton | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Bledsoe | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-1 Benefit Details
|
Blount | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Bradley | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Campbell | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-1 Benefit Details
|
Cannon | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Carroll | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-1 Benefit Details
|
Carter | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-1 Benefit Details
|
Cheatham | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-1 Benefit Details
|
Chester | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Claiborne | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Clay | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Cocke | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Coffee | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Crockett | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Cumberland | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Decatur | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
DeKalb | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-1 Benefit Details
|
Dickson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Dyer | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-3 Benefit Details
|
Fayette | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Fentress | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Franklin | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Gibson | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Giles | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Grainger | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Greene | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Grundy | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Hamblen | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-1 Benefit Details
|
Hamilton | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Hancock | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Hardeman | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Hardin | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-1 Benefit Details
|
Hawkins | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Haywood | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Henderson | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Henry | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-1 Benefit Details
|
Hickman | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Houston | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Humphreys | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Jackson | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Jefferson | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Johnson | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-1 Benefit Details
|
Knox | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Lake | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Lauderdale | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Lawrence | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Lewis | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Lincoln | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-1 Benefit Details
|
Loudon | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-1 Benefit Details
|
Macon | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-1 Benefit Details
|
Madison | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-1 Benefit Details
|
Marion | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Marshall | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Maury | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
McMinn | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
McNairy | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Meigs | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Monroe | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-1 Benefit Details
|
Montgomery | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Moore | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Morgan | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Obion | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Overton | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Perry | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Pickett | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Polk | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Putnam | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Rhea | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Roane | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-1 Benefit Details
|
Robertson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Scott | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-1 Benefit Details
|
Sequatchie | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-1 Benefit Details
|
Sevier | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-3 Benefit Details
|
Shelby | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-1 Benefit Details
|
Smith | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-1 Benefit Details
|
Stewart | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-1 Benefit Details
|
Sullivan | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-1 Benefit Details
|
Sumner | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-3 Benefit Details
|
Tipton | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-1 Benefit Details
|
Trousdale | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-1 Benefit Details
|
Unicoi | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-1 Benefit Details
|
Union | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Van Buren | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Warren | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-1 Benefit Details
|
Washington | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Wayne | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
Weakley | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-2 Benefit Details
|
White | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TN - H5006-016-1 Benefit Details
|
Wilson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Anderson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Andrews | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Angelina | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Aransas | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Atascosa | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Austin | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Bandera | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Bastrop | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Bee | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Bell | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Bexar | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Blanco | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Bosque | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Brown | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Burnet | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Caldwell | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Calhoun | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Callahan | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Camp | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Cass | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Cherokee | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Coke | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Coleman | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Collin | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Colorado | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Comal | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Comanche | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Concho | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Cooke | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Coryell | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Crane | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Dallas | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Delta | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Denton | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
DeWitt | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Eastland | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Ector | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
El Paso | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Ellis | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Erath | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Falls | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Fannin | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Fayette | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Fisher | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Franklin | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Freestone | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Gillespie | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Glasscock | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Goliad | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Gonzales | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Grayson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Gregg | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Guadalupe | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Hamilton | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Harrison | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Hays | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Henderson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Hill | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Hood | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Hopkins | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Houston | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Howard | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Hudspeth | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Hunt | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Jack | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Jackson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Jasper | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Jim Wells | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Johnson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Jones | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Karnes | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Kaufman | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Kendall | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Kimble | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Kleberg | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Lamar | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Lampasas | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Lavaca | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Lee | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Leon | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Limestone | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Live Oak | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Llano | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Madison | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Marion | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Martin | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Mason | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Matagorda | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
McCulloch | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
McLennan | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Medina | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Menard | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Midland | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Mills | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Mitchell | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Montague | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Morris | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Nacogdoches | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Navarro | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Newton | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Nolan | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Nueces | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Palo Pinto | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Panola | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Parker | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Polk | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Rains | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Reagan | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Red River | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Refugio | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Robertson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Rockwall | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Runnels | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Rusk | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Sabine | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
San Augustine | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
San Patricio | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
San Saba | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Schleicher | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Scurry | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Shackelford | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Shelby | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Smith | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Somervell | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Stephens | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Sterling | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Sutton | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Tarrant | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Taylor | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Titus | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Tom Green | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Travis | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Trinity | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Tyler | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Upshur | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Upton | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Van Zandt | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Victoria | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Walker | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Washington | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Wharton | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Williamson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Wilson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Winkler | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Wise | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in TX - H5006-016-1 Benefit Details
|
Wood | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in UT - H5006-016-1 Benefit Details
|
Beaver | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in UT - H5006-016-1 Benefit Details
|
Box Elder | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in UT - H5006-016-1 Benefit Details
|
Cache | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in UT - H5006-016-1 Benefit Details
|
Carbon | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in UT - H5006-016-1 Benefit Details
|
Davis | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in UT - H5006-016-1 Benefit Details
|
Garfield | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in UT - H5006-016-1 Benefit Details
|
Iron | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in UT - H5006-016-1 Benefit Details
|
Juab | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in UT - H5006-016-1 Benefit Details
|
Kane | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in UT - H5006-016-1 Benefit Details
|
Morgan | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in UT - H5006-016-1 Benefit Details
|
Piute | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in UT - H5006-016-1 Benefit Details
|
Rich | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in UT - H5006-016-1 Benefit Details
|
Salt Lake | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in UT - H5006-016-1 Benefit Details
|
Sanpete | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in UT - H5006-016-1 Benefit Details
|
Summit | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in UT - H5006-016-1 Benefit Details
|
Tooele | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in UT - H5006-016-1 Benefit Details
|
Utah | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in UT - H5006-016-1 Benefit Details
|
Wasatch | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in UT - H5006-016-1 Benefit Details
|
Washington | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in UT - H5006-016-1 Benefit Details
|
Weber | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in VA - H5006-016-1 Benefit Details
|
Amelia | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in VA - H5006-016-1 Benefit Details
|
Caroline | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in VA - H5006-016-1 Benefit Details
|
Charles City | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in VA - H5006-016-1 Benefit Details
|
Chesterfield | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in VA - H5006-016-1 Benefit Details
|
Colonial Heights City | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in VA - H5006-016-1 Benefit Details
|
Dinwiddie | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in VA - H5006-016-1 Benefit Details
|
Goochland | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in VA - H5006-016-1 Benefit Details
|
Hanover | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in VA - H5006-016-1 Benefit Details
|
Henrico | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in VA - H5006-016-1 Benefit Details
|
Hopewell City | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in VA - H5006-016-1 Benefit Details
|
King William | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in VA - H5006-016-1 Benefit Details
|
Louisa | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in VA - H5006-016-1 Benefit Details
|
New Kent | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in VA - H5006-016-1 Benefit Details
|
Petersburg City | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in VA - H5006-016-1 Benefit Details
|
Powhatan | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in VA - H5006-016-1 Benefit Details
|
Prince George | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in VA - H5006-016-1 Benefit Details
|
Richmond City | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
Adams | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
Asotin | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-3 Benefit Details
|
Benton | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-2 Benefit Details
|
Chelan | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
Clallam | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
Clark | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
Columbia | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
Cowlitz | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-2 Benefit Details
|
Douglas | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
Ferry | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-3 Benefit Details
|
Franklin | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
Garfield | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-2 Benefit Details
|
Grant | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
Grays Harbor | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
Island | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
Jefferson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
King | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
Kitsap | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-2 Benefit Details
|
Kittitas | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-3 Benefit Details
|
Klickitat | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
Lewis | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
Lincoln | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
Mason | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-3 Benefit Details
|
Okanogan | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
Pacific | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
Pend Oreille | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
Pierce | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
San Juan | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
Skagit | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
Skamania | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
Snohomish | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
Spokane | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
Stevens | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
Thurston | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
Wahkiakum | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
Walla Walla | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
Whatcom | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-1 Benefit Details
|
Whitman | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WA - H5006-016-3 Benefit Details
|
Yakima | $196.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WV - H5006-016-1 Benefit Details
|
Boone | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in WV - H5006-016-1 Benefit Details
|
Clay | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WV - H5006-016-1 Benefit Details
|
Fayette | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WV - H5006-016-1 Benefit Details
|
Kanawha | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in WV - H5006-016-1 Benefit Details
|
Lincoln | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WV - H5006-016-1 Benefit Details
|
Putnam | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Barron | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Brown | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Buffalo | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Burnett | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Calumet | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Columbia | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Dane | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Dodge | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Door | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Dunn | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Fond du Lac | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Green | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Iowa | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Jefferson | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Kewaunee | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Lafayette | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Manitowoc | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Marinette | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Oconto | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Outagamie | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Pepin | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Pierce | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Polk | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Rock | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Sauk | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Shawano | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Sheboygan | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
St. Croix | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Washburn | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Waupaca | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WI - H5006-016-2 Benefit Details
|
Winnebago | $120.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in WY - H5006-016-1 Benefit Details
|
Albany | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WY - H5006-016-1 Benefit Details
|
Big Horn | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WY - H5006-016-1 Benefit Details
|
Campbell | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in WY - H5006-016-1 Benefit Details
|
Crook | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WY - H5006-016-1 Benefit Details
|
Hot Springs | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WY - H5006-016-1 Benefit Details
|
Johnson | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in WY - H5006-016-1 Benefit Details
|
Laramie | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WY - H5006-016-1 Benefit Details
|
Park | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WY - H5006-016-1 Benefit Details
|
Sheridan | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 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 | |||||||||
|
Sterling Option IV (PFFS) in WY - H5006-016-1 Benefit Details
|
Washakie | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
|
Sterling Option IV (PFFS) in WY - H5006-016-1 Benefit Details
|
Weston | $119.00 | $225 | No Gap Coverage | Generic: $10.00 Brand: $36.00 Specialty: 25% | n/a Browse Formulary | |||||
|
|
|
|||||||||
Chart Legend:
Below are a few notes to help with the understanding of the 2010 Medicare Part D Prescription Drug Plan chart above and Search Tips to help you narrow down your list of plans to those that best meet your needs.
Below are a few notes to help with the understanding of the 2010 Medicare Part D Prescription Drug Plan chart above and Search Tips to help you narrow down your list of plans to those that best meet your needs.
|
Prescription Discounts for Everyone
Prescription Discounts are
easy as 1-2-3
easy as 1-2-3
- Locate lowest price drug and pharmacy
- Show card at pharmacy
- Get instant savings!
Your drug discount card is available to you at no cost.
Q1 Quick Links
- Sign-up for our Medicare Part D Newsletter.
- PDP-Facts: 2024 Medicare Part D plan Facts & Figures
- 2024 PDP-Finder: Medicare Part D (Drug Only) Plan Finder
- PDP-Compare: 2023/2024 Medicare Part D plan changes
- 2024 MA-Finder: Medicare Advantage Plan Finder
- MA plan changes 2023 to 2024
- Drug Finder: 2024 Medicare Part D drug search
- Formulary Browser: View any 2024 Medicare plan's drug list
- 2024 Browse Drugs By Letter
- Guide to 2023/2024 Mailings from CMS, Social Security and Plans
- Out-of-Pocket Cost Calculator
- Q1Medicare FAQs: Most Read and Newest Questions & Answers
- Q1Medicare News: Latest Articles
- 2025 Medicare Part D Reminder Service