ACTIQ 200MCG LOZENGE (30 BOT) (NDC: 63459050230)
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 |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
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)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
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)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
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)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
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)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
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)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
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)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
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)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | P Q:120 /30Days | $1,142.50 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
5 |
Tier 5 |
25% | 25% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
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 |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
5 |
Tier 5 |
33% | 33% | P Q:120 /30Days | $1,152.89 |
Browse Plan Formulary |