ALOCRIL 2% EYE DROPS (5 ML BOTDR) (NDC: 00023884205)
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 |
Advantra Elite (PPO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$40.00 | $100.00 | Q:10 /30Days | $84.62 |
Browse Plan Formulary |
Bravo Achieve (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$70.00 | $140.00 | None | $86.06 |
Browse Plan Formulary |
Bravo Achieve (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$70.00 | $140.00 | None | $86.06 |
Browse Plan Formulary |
Bravo Achieve (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$70.00 | $140.00 | None | $86.06 |
Browse Plan Formulary |
Bravo Classic (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$70.00 | $140.00 | None | $86.06 |
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 |
Bravo Classic (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$70.00 | $140.00 | None | $86.06 |
Browse Plan Formulary |
Bravo Classic (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$70.00 | $140.00 | None | $86.06 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
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 |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
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 |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
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 |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
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 |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
FreedomBlue PPO HD Rx (PPO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.12 |
Browse Plan Formulary |
UPMC for Life PPO High Deductible with Rx
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $89.48 |
Browse Plan Formulary |
Aetna Medicare Open Value Plan w/Rx (PFFS)
|
$0.10 |
$0 |
to be determined |
4 |
Tier 4 |
$68.00 | $136.00 | None | $86.01 |
Browse Plan Formulary |
Aetna Medicare Open Value Plan w/Rx (PFFS)
|
$0.10 |
$0 |
to be determined |
4 |
Tier 4 |
$68.00 | $136.00 | None | $86.01 |
Browse Plan Formulary |
Aetna Medicare Open Value Plan w/Rx (PFFS)
|
$0.10 |
$0 |
to be determined |
4 |
Tier 4 |
$68.00 | $136.00 | None | $86.01 |
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 |
Aetna Medicare Open Value Plan w/Rx (PFFS)
|
$0.10 |
$0 |
to be determined |
4 |
Tier 4 |
$68.00 | $136.00 | None | $86.01 |
Browse Plan Formulary |
Aetna Medicare Open Value Plan w/Rx (PFFS)
|
$0.10 |
$0 |
to be determined |
4 |
Tier 4 |
$68.00 | $136.00 | None | $86.01 |
Browse Plan Formulary |
Aetna Medicare Open Value Plan w/Rx (PFFS)
|
$0.10 |
$0 |
to be determined |
4 |
Tier 4 |
$68.00 | $136.00 | None | $86.01 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.26 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.26 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.26 |
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 |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.26 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.26 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.26 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.26 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.26 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.26 |
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 |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.26 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.26 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.26 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.26 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.26 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.26 |
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 |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.26 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.26 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.26 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.26 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.26 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.26 |
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 |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.26 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.26 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.26 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.26 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.26 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.26 |
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 |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.26 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.26 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.26 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.26 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.26 |
Browse Plan Formulary |
SecurityBlue Basic (HMO)
|
$6.50 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.12 |
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 |
SecureHorizons MedicareDirect Rx Plan 150
|
$10.90 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $86.41 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 150
|
$10.90 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $86.41 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $85.32 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $85.32 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $85.32 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $85.32 |
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 |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $85.32 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $85.32 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $85.32 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $85.32 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $85.32 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $85.32 |
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 |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $85.32 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $85.32 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $85.32 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $85.32 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $85.32 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $85.32 |
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 |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $85.32 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $85.32 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $85.32 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $85.32 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $85.32 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.32 |
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 |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.32 |
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 |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.32 |
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 |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.32 |
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 |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.39 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.39 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.39 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.39 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.39 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.39 |
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 |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.39 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.39 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.39 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.39 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.39 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.39 |
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 |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.39 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.39 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.39 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
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 |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
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 |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
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 |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
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 |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
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 |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
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 |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
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 |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
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 |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
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 |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
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 |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.04 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.21 |
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 |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.21 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.21 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.21 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.21 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.21 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.21 |
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 |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.21 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.21 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.21 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.21 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.21 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.21 |
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 |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.21 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.21 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.21 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $86.21 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.32 |
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 |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.32 |
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 |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.32 |
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 |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.32 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.21 |
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 |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.21 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.21 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.21 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.21 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.21 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.21 |
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 |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.21 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.21 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.21 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.21 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.21 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.21 |
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 |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.21 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.21 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.21 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.21 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$19.50 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $85.63 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$19.50 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $85.63 |
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 |
Aetna Medicare Standard Plan (PPO)
|
$19.50 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $85.63 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$19.50 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $85.63 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$19.50 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $85.63 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$19.50 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $85.63 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$19.50 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $85.63 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$19.50 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $85.63 |
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 |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
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 |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
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 |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
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 |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
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 |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
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 |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
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 |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
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 |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
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 |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | Q:10 /30Days | $91.36 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
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 |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
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 |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
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 |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
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 |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $87.83 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $89.67 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $89.67 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $89.67 |
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 |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $89.67 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $89.67 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $85.91 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $85.91 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $85.91 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $85.91 |
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 |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $85.91 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $89.67 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $89.67 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $89.67 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $89.67 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $89.67 |
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 |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $85.91 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $85.91 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $85.91 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $85.91 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $85.91 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $88.16 |
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 |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $88.16 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $88.16 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $88.16 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $88.16 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $88.16 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $88.16 |
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 |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $88.16 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $88.16 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $88.16 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $88.16 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $88.16 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $88.16 |
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 |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $88.16 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $88.16 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $88.16 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $88.16 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $88.16 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $88.16 |
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 |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $88.16 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $88.16 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | None | $88.16 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.39 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.39 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.39 |
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 |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.39 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.39 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.39 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.39 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.39 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.39 |
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 |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.39 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.39 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.39 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.39 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.39 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $86.39 |
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 |
Bravo Freedom (PPO)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $160.00 | None | $86.06 |
Browse Plan Formulary |
Bravo Freedom (PPO)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $160.00 | None | $86.06 |
Browse Plan Formulary |
Bravo Freedom (PPO)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $160.00 | None | $86.06 |
Browse Plan Formulary |
FreedomBlue PPO Select (PPO)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $87.12 |
Browse Plan Formulary |
Evercare Plan MP (PPO)
|
$25.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $245.00 | None | $85.09 |
Browse Plan Formulary |
Evercare Plan MP (PPO)
|
$25.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $245.00 | None | $85.09 |
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 |
Evercare Plan MP (PPO)
|
$25.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $245.00 | None | $85.09 |
Browse Plan Formulary |
Evercare Plan MP (PPO)
|
$25.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $245.00 | None | $85.09 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$27.30 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $85.74 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$27.30 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $85.74 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$27.30 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $85.74 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$27.30 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $85.74 |
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 |
Aetna Medicare Premier Plan (HMO)
|
$27.30 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $85.74 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$27.30 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $85.74 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$27.30 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $85.74 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$27.30 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $85.74 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$27.30 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $85.74 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$27.30 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $85.74 |
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 |
Aetna Medicare Premier Plan (HMO)
|
$27.30 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $85.74 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$27.30 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $85.74 |
Browse Plan Formulary |
SecurityBlue Standard (HMO)
|
$28.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $87.12 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$29.70 |
$0 |
to be determined |
2 |
Tier 2 |
$37.00 | $92.50 | Q:10 /30Days | $85.50 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$29.70 |
$0 |
to be determined |
2 |
Tier 2 |
$37.00 | $92.50 | Q:10 /30Days | $85.50 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$29.70 |
$0 |
to be determined |
2 |
Tier 2 |
$37.00 | $92.50 | Q:10 /30Days | $85.50 |
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 |
Advantra Gold (PPO)
|
$29.70 |
$0 |
to be determined |
2 |
Tier 2 |
$37.00 | $92.50 | Q:10 /30Days | $85.50 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$29.70 |
$0 |
to be determined |
2 |
Tier 2 |
$37.00 | $92.50 | Q:10 /30Days | $85.50 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$29.70 |
$0 |
to be determined |
2 |
Tier 2 |
$37.00 | $92.50 | Q:10 /30Days | $85.50 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$29.70 |
$0 |
to be determined |
2 |
Tier 2 |
$37.00 | $92.50 | Q:10 /30Days | $85.50 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$29.70 |
$0 |
to be determined |
2 |
Tier 2 |
$37.00 | $92.50 | Q:10 /30Days | $85.50 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$29.70 |
$0 |
to be determined |
2 |
Tier 2 |
$37.00 | $92.50 | Q:10 /30Days | $85.50 |
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 |
Advantra Gold (PPO)
|
$29.70 |
$0 |
to be determined |
2 |
Tier 2 |
$37.00 | $92.50 | Q:10 /30Days | $85.50 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$29.70 |
$0 |
to be determined |
2 |
Tier 2 |
$37.00 | $92.50 | Q:10 /30Days | $85.50 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$29.70 |
$0 |
to be determined |
2 |
Tier 2 |
$37.00 | $92.50 | Q:10 /30Days | $85.50 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$29.70 |
$0 |
to be determined |
2 |
Tier 2 |
$37.00 | $92.50 | Q:10 /30Days | $85.50 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$29.70 |
$0 |
to be determined |
2 |
Tier 2 |
$37.00 | $92.50 | Q:10 /30Days | $85.50 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $89.48 |
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 |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $89.48 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $89.48 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $89.48 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $89.48 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $89.48 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $89.48 |
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 |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $89.48 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $89.48 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $89.48 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $89.48 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $89.48 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $89.48 |
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 |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $89.48 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $89.48 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $89.48 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $89.48 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $89.48 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $89.48 |
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 |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $89.48 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $89.48 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $89.48 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $89.48 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $89.48 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $89.48 |
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 |
UPMC for Life Specialty Plan (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $89.48 |
Browse Plan Formulary |
UPMC for Life Specialty Plan (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $89.48 |
Browse Plan Formulary |
UPMC for Life Specialty Plan (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $89.48 |
Browse Plan Formulary |
UPMC for Life HMO Rx (HMO)
|
$33.90 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $89.48 |
Browse Plan Formulary |
UPMC for Life HMO Rx Enhanced (HMO)
|
$34.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $89.48 |
Browse Plan Formulary |
FreedomBlue PPO Classic (PPO)
|
$38.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $87.12 |
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 |
SecurityBlue Deluxe (HMO)
|
$46.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $87.12 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $89.48 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $89.48 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $89.48 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $89.48 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $89.48 |
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 |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $89.48 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $89.48 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $89.48 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $89.48 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $89.48 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $89.48 |
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 |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $89.48 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $89.48 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $89.48 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $89.48 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $89.48 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $89.48 |
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 |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $89.48 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $89.48 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $89.48 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $89.48 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $89.48 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $89.48 |
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 |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $89.48 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $89.48 |
Browse Plan Formulary |
FreedomBlue PPO Platinum (PPO)
|
$83.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $87.12 |
Browse Plan Formulary |