FOCALIN XR 10MG CAPSULE (100 BOT) (NDC: 00078043105)
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 |
Bravo Achieve (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $70.00 | P | $143.76 |
Browse Plan Formulary |
Bravo Achieve (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $70.00 | P | $143.76 |
Browse Plan Formulary |
Bravo Achieve (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $70.00 | P | $143.76 |
Browse Plan Formulary |
Bravo Classic (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $70.00 | P | $140.48 |
Browse Plan Formulary |
Bravo Classic (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $70.00 | P | $140.48 |
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 |
Bravo Classic (HMO)
|
$0.00 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $70.00 | P | $140.48 |
Browse Plan Formulary |
FreedomBlue PPO HD Rx (PPO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.80 |
Browse Plan Formulary |
UPMC for Life PPO High Deductible with Rx
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.94 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.94 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.94 |
Browse Plan Formulary |
|
Plan Name |
Monthly 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 |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.94 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.94 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.94 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.94 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.94 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.94 |
Browse Plan Formulary |
Plan Name |
Monthly 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 |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.94 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.94 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.94 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.94 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.94 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$1.80 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.94 |
Browse Plan Formulary |
Plan Name |
Monthly 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 |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.94 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.94 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.94 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.94 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.94 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.94 |
Browse Plan Formulary |
Plan Name |
Monthly 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 |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.94 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.94 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.94 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.94 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.94 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.94 |
Browse Plan Formulary |
Plan Name |
Monthly 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 |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.94 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.94 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.94 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.94 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$4.00 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.94 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.82 |
Browse Plan Formulary |
Plan Name |
Monthly 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 |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.82 |
Browse Plan Formulary |
Plan Name |
Monthly 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 |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.82 |
Browse Plan Formulary |
Plan Name |
Monthly 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 |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.10 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.82 |
Browse Plan Formulary |
Plan Name |
Monthly 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 |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.71 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.71 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.71 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.71 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.71 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.71 |
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 |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.71 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.71 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.71 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.71 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.71 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.71 |
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 |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.71 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.71 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$12.30 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.71 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
FreedomBlue PFFS Choice Plus (PFFS)
|
$14.60 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.79 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.89 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.89 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.89 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.89 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.89 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.89 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.89 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.89 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.89 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.89 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.89 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.89 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.89 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.89 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.89 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.89 |
Browse Plan Formulary |
Any, Any, Any Gold (PFFS)
|
$14.70 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $70.00 | P | $139.89 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.82 |
Browse Plan Formulary |
Plan Name |
Monthly 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 |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.82 |
Browse Plan Formulary |
Plan Name |
Monthly 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 |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.82 |
Browse Plan Formulary |
Plan Name |
Monthly 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 |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.82 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$14.80 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.82 |
Browse Plan Formulary |
SecurityBlue Basic (HMO)
|
$16.00 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.55 |
Browse Plan Formulary |
Plan Name |
Monthly 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 |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.89 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.89 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.89 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.89 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.89 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.89 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.89 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.89 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.89 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.89 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.89 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.89 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.89 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.89 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.89 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.89 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$16.40 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.89 |
Browse Plan Formulary |
FreedomBlue PPO Select (PPO)
|
$22.70 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $225.00 | None | $140.80 |
Browse Plan Formulary |
Plan Name |
Monthly 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 |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.71 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.71 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.71 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.71 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.71 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.71 |
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 |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.71 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.71 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.71 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.71 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.71 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.71 |
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 |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.71 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.71 |
Browse Plan Formulary |
Any, Any, Any Platinum (PFFS)
|
$23.30 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $60.00 | P | $139.71 |
Browse Plan Formulary |
Bravo Freedom (PPO)
|
$23.70 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $70.00 | P | $140.48 |
Browse Plan Formulary |
Bravo Freedom (PPO)
|
$23.70 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $70.00 | P | $140.48 |
Browse Plan Formulary |
Bravo Freedom (PPO)
|
$23.70 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $70.00 | P | $140.48 |
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 |
SecurityBlue Standard (HMO)
|
$25.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $140.55 |
Browse Plan Formulary |
FreedomBlue PPO Classic (PPO)
|
$31.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $140.80 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Community Living (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Life Specialty Plan (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Life Specialty Plan (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Life Specialty Plan (HMO)
|
$32.10 |
$0 |
to be determined |
3 |
Tier 3 |
$90.00 | $270.00 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
Plan Name |
Monthly 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 HMO Rx (HMO)
|
$33.90 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Life HMO Rx Enhanced (HMO)
|
$34.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
SecurityBlue Deluxe (HMO)
|
$40.10 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $140.55 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
UPMC for Life PPO Rx Enhanced (PPO)
|
$55.10 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P Q:31 /31Days | $144.98 |
Browse Plan Formulary |
FreedomBlue PPO Platinum (PPO)
|
$66.60 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $140.80 |
Browse Plan Formulary |