ACCUTANE 10MG CAPSULE (100 (10X10) BLPK) (NDC: 00004015549)
2010 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
Plan Name |
Monthly Prem. |
De- duct- ible | Does Plan Offer Gap Coverage | Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Plan’s Avg. Retail Drug Price 30-Day |
Tier Nbr. |
Tier Desc. |
30-Day Prfrd. Pharm |
90-Day Mail Order |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
|
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | None | $1,119.46 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible | Gap Coverage | Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 4 |
Tier 4 |
$55.00 | $137.50 | None | $1,086.68 |
Browse Plan Formulary |