IRESSA 250MG TABLET (30 BOT) (NDC: 00310048230)
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 |
Altius Advantra Option 1 (HMO-POS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 1 (HMO-POS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 1 (HMO-POS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 1 (HMO-POS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 1 (HMO-POS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
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 |
Altius Advantra Option 1 (HMO-POS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 1 (HMO-POS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 1 (HMO-POS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 1 (HMO-POS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 1 (HMO-POS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 1 (HMO-POS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
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 |
Altius Advantra Option 1 (HMO-POS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 1 (HMO-POS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 1 (HMO-POS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 1 (HMO-POS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Evercare Plan MH-POS (HMO-POS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
Evercare Plan MH-POS (HMO-POS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Evercare Plan MH-POS (HMO-POS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
Evercare Plan MH-POS (HMO-POS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
Evercare Plan MH-POS (HMO-POS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
Evercare Plan MH-POS (HMO-POS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
Evercare Plan MH-POS (HMO-POS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,535.17 |
Browse Plan Formulary |
Plan Name |
Monthly 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)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,535.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,535.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,535.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,535.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,535.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,535.17 |
Browse Plan Formulary |
Plan Name |
Monthly 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)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,535.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,535.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,535.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,535.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,535.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,535.17 |
Browse Plan Formulary |
Plan Name |
Monthly 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)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,535.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,535.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,535.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,535.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,535.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,535.17 |
Browse Plan Formulary |
Plan Name |
Monthly 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)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,535.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,535.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,535.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,535.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,535.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,535.17 |
Browse Plan Formulary |
Plan Name |
Monthly 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)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,535.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,535.17 |
Browse Plan Formulary |
Sierra Optima Select Rx (PFFS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,918.56 |
Browse Plan Formulary |
Sierra Optima Select Rx (PFFS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,918.56 |
Browse Plan Formulary |
Sierra Optima Select Rx (PFFS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,918.56 |
Browse Plan Formulary |
Sierra Optima Select Rx (PFFS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,918.56 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sierra Optima Select Rx (PFFS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,918.56 |
Browse Plan Formulary |
Sierra Optima Select Rx (PFFS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,918.56 |
Browse Plan Formulary |
Sierra Optima Select Rx (PFFS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,918.56 |
Browse Plan Formulary |
Sierra Optima Select Rx (PFFS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,918.56 |
Browse Plan Formulary |
Sierra Optima Select Rx (PFFS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,918.56 |
Browse Plan Formulary |
Sierra Optima Select Rx (PFFS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,918.56 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sierra Optima Select Rx (PFFS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,918.56 |
Browse Plan Formulary |
Sierra Optima Select Rx (PFFS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,918.56 |
Browse Plan Formulary |
Sierra Optima Select Rx (PFFS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,918.56 |
Browse Plan Formulary |
Sierra Optima Select Rx (PFFS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,918.56 |
Browse Plan Formulary |
Sierra Optima Select Rx (PFFS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,918.56 |
Browse Plan Formulary |
Sierra Optima Select Rx (PFFS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,918.56 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sierra Optima Select Rx (PFFS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,918.56 |
Browse Plan Formulary |
Sierra Optima Select Rx (PFFS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,918.56 |
Browse Plan Formulary |
Sierra Optima Select Rx (PFFS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,918.56 |
Browse Plan Formulary |
Sierra Optima Select Rx (PFFS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,918.56 |
Browse Plan Formulary |
Sierra Optima Select Rx (PFFS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,918.56 |
Browse Plan Formulary |
Sierra Optima Select Rx (PFFS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,918.56 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sierra Optima Select Rx (PFFS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,918.56 |
Browse Plan Formulary |
Sierra Optima Select Rx (PFFS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,918.56 |
Browse Plan Formulary |
Sierra Optima Select Rx (PFFS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,918.56 |
Browse Plan Formulary |
Sierra Optima Select Rx (PFFS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,918.56 |
Browse Plan Formulary |
Sierra Optima Select Rx (PFFS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,918.56 |
Browse Plan Formulary |
Sierra Optima Select Rx (PFFS)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,918.56 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 51 (
|
$11.00 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,837.91 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sierra Optima Choice Rx (PFFS)
|
$12.30 |
$0 |
to be determined |
4 |
Tier 4 |
33% | 33% | None | $1,918.56 |
Browse Plan Formulary |
HumanaChoice H4606-001 (PPO)
|
$23.20 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-057 (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-057 (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-057 (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-057 (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Plan Name |
Monthly 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 H2944-057 (PFFS)
|
$23.30 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-055 (PFFS)
|
$24.30 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-055 (PFFS)
|
$24.30 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-055 (PFFS)
|
$24.30 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-055 (PFFS)
|
$24.30 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-055 (PFFS)
|
$24.30 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Plan Name |
Monthly 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 H2944-055 (PFFS)
|
$24.30 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-055 (PFFS)
|
$24.30 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-055 (PFFS)
|
$24.30 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-055 (PFFS)
|
$24.30 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-055 (PFFS)
|
$24.30 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-055 (PFFS)
|
$24.30 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Plan Name |
Monthly 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 H2944-055 (PFFS)
|
$24.30 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-055 (PFFS)
|
$24.30 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-055 (PFFS)
|
$24.30 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-055 (PFFS)
|
$24.30 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-055 (PFFS)
|
$24.30 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-055 (PFFS)
|
$24.30 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Plan Name |
Monthly 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 H2944-055 (PFFS)
|
$24.30 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-055 (PFFS)
|
$24.30 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-055 (PFFS)
|
$24.30 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-055 (PFFS)
|
$24.30 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-055 (PFFS)
|
$24.30 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-055 (PFFS)
|
$24.30 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Plan Name |
Monthly 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 H2944-058 (PFFS)
|
$32.20 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-058 (PFFS)
|
$32.20 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-058 (PFFS)
|
$32.20 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-058 (PFFS)
|
$32.20 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-058 (PFFS)
|
$32.20 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-056 (PFFS)
|
$33.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Plan Name |
Monthly 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 H2944-056 (PFFS)
|
$33.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-056 (PFFS)
|
$33.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-056 (PFFS)
|
$33.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-056 (PFFS)
|
$33.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-056 (PFFS)
|
$33.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-056 (PFFS)
|
$33.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Plan Name |
Monthly 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 H2944-056 (PFFS)
|
$33.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-056 (PFFS)
|
$33.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-056 (PFFS)
|
$33.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-056 (PFFS)
|
$33.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-056 (PFFS)
|
$33.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-056 (PFFS)
|
$33.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Plan Name |
Monthly 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 H2944-056 (PFFS)
|
$33.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-056 (PFFS)
|
$33.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-056 (PFFS)
|
$33.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-056 (PFFS)
|
$33.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-056 (PFFS)
|
$33.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-056 (PFFS)
|
$33.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Plan Name |
Monthly 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 H2944-056 (PFFS)
|
$33.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-056 (PFFS)
|
$33.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-056 (PFFS)
|
$33.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Humana Gold Choice H2944-056 (PFFS)
|
$33.10 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,756.56 |
Browse Plan Formulary |
Altius Advantra Option 2 (HMO-POS)
|
$33.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 2 (HMO-POS)
|
$33.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
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 |
Altius Advantra Option 2 (HMO-POS)
|
$33.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 2 (HMO-POS)
|
$33.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 2 (HMO-POS)
|
$33.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 2 (HMO-POS)
|
$33.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 2 (HMO-POS)
|
$33.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 2 (HMO-POS)
|
$33.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
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 |
Altius Advantra Option 2 (HMO-POS)
|
$33.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 2 (HMO-POS)
|
$33.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 2 (HMO-POS)
|
$33.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 2 (HMO-POS)
|
$33.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 2 (HMO-POS)
|
$33.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 2 (HMO-POS)
|
$33.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
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 |
Altius Advantra Option 2 (HMO-POS)
|
$33.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 2 (HMO-POS)
|
$33.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 2 (HMO-POS)
|
$33.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 2 (HMO-POS)
|
$33.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 2 (HMO-POS)
|
$33.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 2 (HMO-POS)
|
$33.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
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 |
Altius Advantra Option 2 (HMO-POS)
|
$33.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 2 (HMO-POS)
|
$33.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 2 (HMO-POS)
|
$33.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 2 (HMO-POS)
|
$33.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 2 (HMO-POS)
|
$33.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 2 (HMO-POS)
|
$33.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
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 |
Altius Advantra Option 2 (HMO-POS)
|
$33.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Altius Advantra Option 2 (HMO-POS)
|
$33.50 |
$0 |
to be determined |
4 |
Tier 4 |
33% | n/a | Q:30 /30Days | $1,775.66 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,838.03 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,524.99 |
Browse Plan Formulary |