ARTHROTEC 50 50MG TABLET -200MCG (60 CT) (60 BOT) (NDC: 00025141160)
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 |
3 |
Tier 3 |
$69.00 | $207.00 | None | $233.17 |
Browse Plan Formulary |
Advantra Elite (PPO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$69.00 | $207.00 | None | $233.33 |
Browse Plan Formulary |
Advantra Silver (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$64.00 | $192.00 | None | $233.37 |
Browse Plan Formulary |
Advantra Silver (PPO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$66.00 | $198.00 | None | $233.33 |
Browse Plan Formulary |
Bravo Achieve (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$70.00 | $140.00 | None | $237.11 |
Browse Plan Formulary |
Plan Name |
Monthly 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 Achieve (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$70.00 | $140.00 | None | $237.11 |
Browse Plan Formulary |
Bravo Achieve (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$70.00 | $140.00 | None | $237.11 |
Browse Plan Formulary |
Bravo Classic (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$70.00 | $140.00 | None | $237.11 |
Browse Plan Formulary |
Bravo Classic (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$70.00 | $140.00 | None | $237.11 |
Browse Plan Formulary |
Bravo Classic (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$70.00 | $140.00 | None | $237.11 |
Browse Plan Formulary |
FreedomBlue PPO HD Rx (PPO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.91 |
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 |
Unison Advantage Choice (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$65.00 | $185.00 | None | $233.93 |
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 | $245.09 |
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 | $235.29 |
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 | $235.29 |
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 | $235.29 |
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 | $235.29 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $235.29 |
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 | $235.29 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.68 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.68 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.68 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.68 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.68 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.68 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.68 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.68 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.68 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.68 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.68 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.68 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.68 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.68 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.68 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.68 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.68 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.68 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.68 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.68 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.68 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.68 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.68 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.68 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.68 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.68 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.68 |
Browse Plan Formulary |
SecurityBlue Basic (HMO)
|
$6.50 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.91 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 150
|
$10.90 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $233.68 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecureHorizons MedicareDirect Rx Plan 150
|
$10.90 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $233.68 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $234.06 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $234.06 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $234.06 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $234.06 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $234.06 |
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 |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $234.06 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $234.06 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $234.06 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $234.06 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $234.06 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $234.06 |
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 |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $234.06 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $234.06 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $234.06 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $234.06 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $234.06 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $234.06 |
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 |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $234.06 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $234.06 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $234.06 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | None | $234.06 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.78 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.78 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $236.78 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.78 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.78 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.78 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.78 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.78 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $236.78 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.78 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.78 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.78 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.78 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.78 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $236.78 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.78 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.78 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.78 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.78 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.67 |
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 |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.67 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.67 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.67 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.67 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.67 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.67 |
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 |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.67 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.67 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.67 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.67 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.67 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.67 |
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 |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.67 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.67 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.86 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.74 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.74 |
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 |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.74 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.74 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.74 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.74 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.74 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.74 |
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 |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.74 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.74 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.74 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.74 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.74 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.74 |
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 |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.74 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.74 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
4 |
Tier 4 |
$70.00 | $140.00 | None | $236.74 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.78 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.78 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.78 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $236.78 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.78 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.78 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.78 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.78 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.78 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $236.78 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.78 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.78 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.78 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.78 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.78 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $236.78 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.78 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.78 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.78 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.74 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.74 |
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 |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.74 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.74 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.74 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.74 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.74 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.74 |
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 |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.74 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.74 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.74 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.74 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.74 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.74 |
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 |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.74 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.74 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.74 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$19.50 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $234.03 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$19.50 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $234.03 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$19.50 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $234.03 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $234.03 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$19.50 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $234.03 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$19.50 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $234.03 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$19.50 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $234.03 |
Browse Plan Formulary |
Aetna Medicare Standard Plan (PPO)
|
$19.50 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $234.03 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $251.13 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.67 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.67 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.67 |
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 |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.67 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.67 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.67 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.67 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.67 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.67 |
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 |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.67 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.67 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.67 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.67 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.67 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $120.00 | None | $236.67 |
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 |
Bravo Freedom (PPO)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $160.00 | None | $237.11 |
Browse Plan Formulary |
Bravo Freedom (PPO)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $160.00 | None | $237.11 |
Browse Plan Formulary |
Bravo Freedom (PPO)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $160.00 | None | $237.11 |
Browse Plan Formulary |
FreedomBlue PPO Select (PPO)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $237.91 |
Browse Plan Formulary |
Evercare Plan MP (PPO)
|
$25.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $245.00 | None | $233.71 |
Browse Plan Formulary |
Evercare Plan MP (PPO)
|
$25.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $245.00 | None | $233.71 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $233.71 |
Browse Plan Formulary |
Evercare Plan MP (PPO)
|
$25.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $245.00 | None | $233.71 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$27.30 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $234.57 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$27.30 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $234.57 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$27.30 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $234.57 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$27.30 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $234.57 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $234.57 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$27.30 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $234.57 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$27.30 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $234.57 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$27.30 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $234.57 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$27.30 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $234.57 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$27.30 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $234.57 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $234.57 |
Browse Plan Formulary |
Aetna Medicare Premier Plan (HMO)
|
$27.30 |
$0 |
to be determined |
4 |
Tier 4 |
$80.00 | $160.00 | None | $234.57 |
Browse Plan Formulary |
SecurityBlue Standard (HMO)
|
$28.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $237.91 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$29.70 |
$0 |
to be determined |
3 |
Tier 3 |
$70.00 | $210.00 | None | $233.33 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$29.70 |
$0 |
to be determined |
3 |
Tier 3 |
$70.00 | $210.00 | None | $233.33 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$29.70 |
$0 |
to be determined |
3 |
Tier 3 |
$70.00 | $210.00 | None | $233.33 |
Browse Plan Formulary |
Plan Name |
Monthly 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 |
3 |
Tier 3 |
$70.00 | $210.00 | None | $233.33 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$29.70 |
$0 |
to be determined |
3 |
Tier 3 |
$70.00 | $210.00 | None | $233.33 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$29.70 |
$0 |
to be determined |
3 |
Tier 3 |
$70.00 | $210.00 | None | $233.33 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$29.70 |
$0 |
to be determined |
3 |
Tier 3 |
$70.00 | $210.00 | None | $233.33 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$29.70 |
$0 |
to be determined |
3 |
Tier 3 |
$70.00 | $210.00 | None | $233.33 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$29.70 |
$0 |
to be determined |
3 |
Tier 3 |
$70.00 | $210.00 | None | $233.33 |
Browse Plan Formulary |
Plan Name |
Monthly 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 |
3 |
Tier 3 |
$70.00 | $210.00 | None | $233.33 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$29.70 |
$0 |
to be determined |
3 |
Tier 3 |
$70.00 | $210.00 | None | $233.33 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$29.70 |
$0 |
to be determined |
3 |
Tier 3 |
$70.00 | $210.00 | None | $233.33 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$29.70 |
$0 |
to be determined |
3 |
Tier 3 |
$70.00 | $210.00 | None | $233.33 |
Browse Plan Formulary |
Advantra Gold (PPO)
|
$29.70 |
$0 |
to be determined |
3 |
Tier 3 |
$70.00 | $210.00 | None | $233.33 |
Browse Plan Formulary |
Advantra Gold (HMO)
|
$30.30 |
$0 |
to be determined |
3 |
Tier 3 |
$69.00 | $207.00 | None | $233.33 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $245.09 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $245.09 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $245.09 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $245.09 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $245.09 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $245.09 |
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 |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $245.09 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $245.09 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $245.09 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $245.09 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $245.09 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $245.09 |
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 |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $245.09 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $245.09 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $245.09 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $245.09 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $245.09 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $245.09 |
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 |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $245.09 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $245.09 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $245.09 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $245.09 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $245.09 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $245.09 |
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 |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $245.09 |
Browse Plan Formulary |
UPMC for Life Specialty Plan (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $245.09 |
Browse Plan Formulary |
UPMC for Life Specialty Plan (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $245.09 |
Browse Plan Formulary |
UPMC for Life Specialty Plan (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | None | $245.09 |
Browse Plan Formulary |
UPMC for Life HMO Rx (HMO)
|
$33.90 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $245.09 |
Browse Plan Formulary |
UPMC for Life HMO Rx Enhanced (HMO)
|
$34.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $245.09 |
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 |
FreedomBlue PPO Classic (PPO)
|
$38.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $237.91 |
Browse Plan Formulary |
SecurityBlue Deluxe (HMO)
|
$46.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $237.91 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $245.09 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $245.09 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $245.09 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $245.09 |
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 |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $245.09 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $245.09 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $245.09 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $245.09 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $245.09 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $245.09 |
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 |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $245.09 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $245.09 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $245.09 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $245.09 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $245.09 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $245.09 |
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 |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $245.09 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $245.09 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $245.09 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $245.09 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $245.09 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $245.09 |
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 |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $245.09 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $245.09 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | None | $245.09 |
Browse Plan Formulary |
FreedomBlue PPO Platinum (PPO)
|
$83.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $237.91 |
Browse Plan Formulary |