ACTIQ 1200MCG LOZENGE (30 BOT) (NDC: 63459051230)
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 |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 Sapphire (PPO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 Sapphire (PPO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 Sapphire (PPO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 Sapphire (PPO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
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 | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
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 | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
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 | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
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 | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
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 | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
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 | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
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 | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
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 | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
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 | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
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 | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
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 | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
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 | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $2,724.77 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$30.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$30.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$30.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$30.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 Sapphire (PPO)
|
$30.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$30.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$30.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$30.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$30.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$35.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,644.60 |
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 Sapphire (PPO)
|
$35.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,644.60 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$35.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,644.60 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$35.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,644.60 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$35.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,644.60 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$35.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,644.60 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$35.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,644.60 |
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 Sapphire (PPO)
|
$35.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,644.60 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$35.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,644.60 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$35.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,644.60 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$35.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,644.60 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$35.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,644.60 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$35.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,644.60 |
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 Sapphire (PPO)
|
$35.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,644.60 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 Sapphire (PPO)
|
$40.50 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 Sapphire (PPO)
|
$40.50 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 Sapphire (PPO)
|
$40.50 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
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 | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 | to be determined | 5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $2,749.26 |
Browse Plan Formulary |