INTRALIPID PHARMACY BULK PACKAGE FAT EMULSION 1.7-1.2-30GM 500ML BAG (500 ML BAG) (NDC: 00338052003)
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 |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,067.70 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,067.70 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,067.70 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,067.70 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,067.70 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,067.70 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,067.70 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,067.70 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,067.70 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,067.70 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,067.70 |
Browse Plan Formulary |
|
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,067.70 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,067.70 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,067.70 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,067.70 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Value (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Select (HMO)
|
$10.10 |
$310 |
to be determined |
2 |
Tier 2 |
25% | 25% | P | $1,043.95 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HealthSpring HealthyAdvantage Select (HMO)
|
$10.10 |
$310 |
to be determined |
2 |
Tier 2 |
25% | 25% | P | $1,043.95 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
VIVA Medicare Plus Rx Gold (HMO)
|
$17.90 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $1,016.13 |
Browse Plan Formulary |
VIVA Medicare Plus Rx Gold (HMO)
|
$17.90 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $1,016.13 |
Browse Plan Formulary |
VIVA Medicare Plus Rx Gold (HMO)
|
$17.90 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $1,016.13 |
Browse Plan Formulary |
VIVA Medicare Plus Rx Gold (HMO)
|
$17.90 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $1,016.13 |
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 |
VIVA Medicare Plus Rx Gold (HMO)
|
$17.90 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $1,016.13 |
Browse Plan Formulary |
VIVA Medicare Plus Rx Gold (HMO)
|
$17.90 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $1,016.13 |
Browse Plan Formulary |
VIVA Medicare Plus Rx Gold (HMO)
|
$17.90 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $1,016.13 |
Browse Plan Formulary |
VIVA Medicare Plus Rx Gold (HMO)
|
$17.90 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $1,016.13 |
Browse Plan Formulary |
VIVA Medicare Plus Rx Gold (HMO)
|
$17.90 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $1,016.13 |
Browse Plan Formulary |
VIVA Medicare Plus Rx Gold (HMO)
|
$17.90 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $1,016.13 |
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 |
VIVA Medicare Plus Rx Gold (HMO)
|
$17.90 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $1,016.13 |
Browse Plan Formulary |
VIVA Medicare Plus Rx Gold (HMO)
|
$17.90 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $1,016.13 |
Browse Plan Formulary |
VIVA Medicare Plus Rx Gold (HMO)
|
$17.90 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $1,016.13 |
Browse Plan Formulary |
VIVA Medicare Plus Rx Gold (HMO)
|
$17.90 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $1,016.13 |
Browse Plan Formulary |
VIVA Medicare Plus Rx Gold (HMO)
|
$17.90 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $1,016.13 |
Browse Plan Formulary |
VIVA Medicare Plus Rx Gold (HMO)
|
$17.90 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $1,016.13 |
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 |
VIVA Medicare Plus Rx Gold (HMO)
|
$17.90 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $1,016.13 |
Browse Plan Formulary |
VIVA Medicare Plus Rx Gold (HMO)
|
$17.90 |
$0 |
to be determined |
2 |
Tier 2 |
$30.00 | $75.00 | P | $1,016.13 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$20.00 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,057.26 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$20.00 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,057.26 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
Plan Name |
Monthly 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 |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
Plan Name |
Monthly 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 |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
Plan Name |
Monthly 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 |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
Plan Name |
Monthly 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 |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
Plan Name |
Monthly 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 |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
Plan Name |
Monthly 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 |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
Plan Name |
Monthly 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 |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $893.44 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,057.26 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,057.26 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,068.66 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,068.66 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,068.66 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,068.66 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,068.66 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,068.66 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,068.66 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,068.66 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
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 |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
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 |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
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 |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
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 |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
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 |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
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 |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
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 |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,042.86 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-110 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-110 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-110 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-110 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-110 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-110 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-110 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-110 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-110 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-110 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-110 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-109 (PFFS)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-109 (PFFS)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-109 (PFFS)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-109 (PFFS)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-109 (PFFS)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-109 (PFFS)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-109 (PFFS)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-109 (PFFS)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-109 (PFFS)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-109 (PFFS)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-109 (PFFS)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P | $1,020.90 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Special Needs Plan (PPO)
|
$30.70 |
$310 |
to be determined |
4 |
Tier 4 |
25% | 25% | None | $1,071.21 |
Browse Plan Formulary |
VIVA Medicare Plus Rx Extra Care (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,016.13 |
Browse Plan Formulary |
VIVA Medicare Plus Rx Extra Care (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,016.13 |
Browse Plan Formulary |
VIVA Medicare Plus Rx Extra Care (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,016.13 |
Browse Plan Formulary |
VIVA Medicare Plus Rx Extra Care (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,016.13 |
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 |
VIVA Medicare Plus Rx Extra Care (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,016.13 |
Browse Plan Formulary |
VIVA Medicare Plus Rx Extra Care (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,016.13 |
Browse Plan Formulary |
VIVA Medicare Plus Rx Extra Care (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,016.13 |
Browse Plan Formulary |
VIVA Medicare Plus Rx Extra Care (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,016.13 |
Browse Plan Formulary |
VIVA Medicare Plus Rx Extra Care (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,016.13 |
Browse Plan Formulary |
VIVA Medicare Plus Rx Extra Care (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,016.13 |
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 |
VIVA Medicare Plus Rx Extra Care (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,016.13 |
Browse Plan Formulary |
VIVA Medicare Plus Rx Extra Care (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,016.13 |
Browse Plan Formulary |
VIVA Medicare Plus Rx Extra Care (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,016.13 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,071.21 |
Browse Plan Formulary |
HumanaChoice R5826-001 (Regional PPO)
|
$36.20 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | P | $926.70 |
Browse Plan Formulary |
HealthSpring HealthyLiving Premier (HMO)
|
$38.90 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | P | $1,045.75 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HealthSpring HealthyLiving Premier (HMO)
|
$38.90 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | P | $1,045.75 |
Browse Plan Formulary |
HealthSpring HealthyLiving Premier (HMO)
|
$38.90 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | P | $1,045.75 |
Browse Plan Formulary |
HealthSpring HealthyLiving Premier (HMO)
|
$38.90 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | P | $1,045.75 |
Browse Plan Formulary |
HealthSpring HealthyLiving Premier (HMO)
|
$38.90 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | P | $1,045.75 |
Browse Plan Formulary |
HealthSpring HealthyLiving Premier (HMO)
|
$38.90 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | P | $1,045.75 |
Browse Plan Formulary |
HealthSpring HealthyLiving Premier (HMO)
|
$38.90 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | P | $1,045.75 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HealthSpring HealthyLiving Premier (HMO)
|
$38.90 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | P | $1,045.75 |
Browse Plan Formulary |
HealthSpring HealthyLiving Premier (HMO)
|
$38.90 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | P | $1,045.75 |
Browse Plan Formulary |
HealthSpring HealthyLiving Premier (HMO)
|
$38.90 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | P | $1,045.75 |
Browse Plan Formulary |
HealthSpring HealthyLiving Premier (HMO)
|
$38.90 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | P | $1,045.75 |
Browse Plan Formulary |
HealthSpring HealthyLiving Premier (HMO)
|
$38.90 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | P | $1,045.75 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,049.05 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,049.05 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,049.05 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,049.05 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,049.05 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,049.05 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,049.05 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,049.05 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,049.05 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,049.05 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,049.05 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,049.05 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,049.05 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,049.05 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,049.05 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,049.05 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,049.05 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,049.05 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,049.05 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,049.05 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,049.05 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,049.05 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,049.05 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,049.05 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,049.05 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,049.05 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,049.05 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,049.05 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,049.05 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,049.05 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,049.05 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,049.05 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,049.05 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,049.05 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,049.05 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,049.05 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,049.05 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,049.05 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,049.05 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,049.05 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,049.05 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,049.05 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $887.65 |
Browse Plan Formulary |
HealthSpring OptimaCare (HMO)
|
$60.60 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,045.75 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HealthSpring OptimaCare (HMO)
|
$60.60 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,045.75 |
Browse Plan Formulary |
HealthSpring OptimaCare (HMO)
|
$60.60 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,045.75 |
Browse Plan Formulary |
HealthSpring OptimaCare (HMO)
|
$60.60 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,045.75 |
Browse Plan Formulary |
HealthSpring OptimaCare (HMO)
|
$60.60 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,045.75 |
Browse Plan Formulary |
HealthSpring OptimaCare (HMO)
|
$60.60 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,045.75 |
Browse Plan Formulary |
HealthSpring OptimaCare (HMO)
|
$60.60 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,045.75 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HealthSpring OptimaCare (HMO)
|
$60.60 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,045.75 |
Browse Plan Formulary |
HealthSpring OptimaCare (HMO)
|
$60.60 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,045.75 |
Browse Plan Formulary |
HealthSpring OptimaCare (HMO)
|
$60.60 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,045.75 |
Browse Plan Formulary |
HealthSpring OptimaCare (HMO)
|
$60.60 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,045.75 |
Browse Plan Formulary |
HealthSpring OptimaCare (HMO)
|
$60.60 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,045.75 |
Browse Plan Formulary |
HealthSpring OptimaCare (HMO)
|
$60.60 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,045.75 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HealthSpring OptimaCare (HMO)
|
$60.60 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,045.75 |
Browse Plan Formulary |
HealthSpring OptimaCare (HMO)
|
$60.60 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,045.75 |
Browse Plan Formulary |
HealthSpring OptimaCare (HMO)
|
$60.60 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,045.75 |
Browse Plan Formulary |
HealthSpring OptimaCare (HMO)
|
$60.60 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,045.75 |
Browse Plan Formulary |
HealthSpring OptimaCare (HMO)
|
$60.60 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,045.75 |
Browse Plan Formulary |
HealthSpring OptimaCare (HMO)
|
$60.60 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,045.75 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HealthSpring OptimaCare (HMO)
|
$60.60 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,045.75 |
Browse Plan Formulary |
HealthSpring OptimaCare (HMO)
|
$60.60 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | P | $1,045.75 |
Browse Plan Formulary |