QUALAQUIN 324MG CAPSULE (NDC: 13310015307)
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 |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.26 |
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 |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.26 |
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 |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.26 |
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 |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.26 |
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 |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.26 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$0.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.26 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Preferred Ea
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $90.00 | None | $1,043.59 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Preferred Ea
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $90.00 | None | $1,043.59 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Preferred Ea
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $90.00 | None | $1,043.59 |
Browse Plan Formulary |
Plan Name |
Monthly 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 Preferred Ea
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $90.00 | None | $1,043.59 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Preferred Ea
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $90.00 | None | $1,043.59 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Preferred Ea
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $90.00 | None | $1,043.59 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Preferred Ea
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $90.00 | None | $1,043.59 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Preferred Ea
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $90.00 | None | $1,043.59 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Preferred Ea
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $90.00 | None | $1,043.59 |
Browse Plan Formulary |
Plan Name |
Monthly 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 Preferred Ea
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $90.00 | None | $1,043.59 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Preferred Ea
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$30.00 | $90.00 | None | $1,043.59 |
Browse Plan Formulary |
Humana Gold Choice H2944-091 (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-091 (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-091 (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-091 (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
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 |
Humana Gold Choice H2944-091 (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-091 (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-091 (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-091 (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-091 (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-091 (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
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 |
Humana Gold Choice H2944-091 (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-091 (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-091 (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-091 (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-091 (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-091 (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
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 |
Humana Gold Choice H2944-091 (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-091 (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-091 (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-091 (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-091 (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-091 (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
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 |
Humana Gold Choice H2944-091 (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-091 (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-091 (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 55 (
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.09 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
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 |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
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 |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
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 |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
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 |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
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 |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
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 |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
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 |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
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 |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
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 |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
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 |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
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 |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
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 |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$85.00 | $212.50 | P | $1,105.17 |
Browse Plan Formulary |
Windsor Medicare Extra Emerald Plan (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $105.00 | None | $1,036.23 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 58 (
|
$12.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.05 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 58 (
|
$12.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.05 |
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 |
SecureHorizons MedicareDirect Rx Plan 58 (
|
$12.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.05 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 58 (
|
$12.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.05 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 58 (
|
$12.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.05 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 58 (
|
$12.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.05 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 58 (
|
$12.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.05 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 58 (
|
$12.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.05 |
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 |
SecureHorizons MedicareDirect Rx Plan 58 (
|
$12.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.05 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 58 (
|
$12.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.05 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 58 (
|
$12.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.05 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 58 (
|
$12.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.05 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 58 (
|
$12.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.05 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 58 (
|
$12.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.05 |
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 |
SecureHorizons MedicareDirect Rx Plan 58 (
|
$12.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.05 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 58 (
|
$12.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.05 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 58 (
|
$12.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.05 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 58 (
|
$12.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.05 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 58 (
|
$12.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.05 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 58 (
|
$12.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.05 |
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 |
SecureHorizons MedicareDirect Rx Plan 58 (
|
$12.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.05 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 58 (
|
$12.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.05 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 58 (
|
$12.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.05 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 58 (
|
$12.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.05 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 58 (
|
$12.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.05 |
Browse Plan Formulary |
SecureHorizons MedicareDirect Rx Plan 58 (
|
$12.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $230.00 | P | $1,029.05 |
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 |
Windsor Medicare Extra Gold Plan (HMO)
|
$15.80 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $105.00 | None | $1,036.23 |
Browse Plan Formulary |
AARP MedicareComplete Plus Plan 2 (HMO-POS
|
$18.60 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,028.98 |
Browse Plan Formulary |
AARP MedicareComplete Plus Plan 2 (HMO-POS
|
$18.60 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,028.98 |
Browse Plan Formulary |
AARP MedicareComplete Plus Plan 2 (HMO-POS
|
$18.60 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,028.98 |
Browse Plan Formulary |
AARP MedicareComplete Plus Plan 2 (HMO-POS
|
$18.60 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,028.98 |
Browse Plan Formulary |
AARP MedicareComplete Plus Plan 2 (HMO-POS
|
$18.60 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,028.98 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
AARP MedicareComplete Plus Plan 2 (HMO-POS
|
$18.60 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,028.98 |
Browse Plan Formulary |
AARP MedicareComplete Plus Plan 2 (HMO-POS
|
$18.60 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,028.98 |
Browse Plan Formulary |
AARP MedicareComplete Plus Plan 2 (HMO-POS
|
$18.60 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,028.98 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$18.80 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,028.82 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$18.80 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,028.82 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$18.80 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,028.82 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
AARP MedicareComplete Plan 2 (HMO)
|
$18.80 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,028.82 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$18.80 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,028.82 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$18.80 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,028.82 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$18.80 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,028.82 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$18.80 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,028.82 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$18.80 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,028.82 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
AARP MedicareComplete Plan 2 (HMO)
|
$18.80 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,028.82 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$18.80 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,028.82 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$18.80 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,028.82 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$18.80 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,028.82 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$18.80 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,028.82 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$18.80 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,028.82 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
AARP MedicareComplete Plan 2 (HMO)
|
$18.80 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,028.82 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$18.80 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,028.82 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$18.80 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,028.82 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$18.80 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,028.82 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$18.80 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | P | $1,028.82 |
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 | $1,057.52 |
Browse Plan Formulary |
Plan Name |
Monthly 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
|
$20.00 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,057.52 |
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 | $1,057.52 |
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 | $1,057.52 |
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 | $1,057.52 |
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 | $1,057.52 |
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 | $1,057.52 |
Browse Plan Formulary |
Plan Name |
Monthly 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
|
$20.00 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,057.52 |
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 | $1,057.52 |
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 | $1,057.52 |
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 | $1,057.52 |
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 | $1,057.52 |
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 | $1,057.52 |
Browse Plan Formulary |
Plan Name |
Monthly 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
|
$20.00 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,057.52 |
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 | $1,057.52 |
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 | $1,057.52 |
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 | $1,057.52 |
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 | $1,057.52 |
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 | $1,057.52 |
Browse Plan Formulary |
Plan Name |
Monthly 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
|
$20.00 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,057.52 |
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 | $1,057.52 |
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 | $1,057.52 |
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 | $1,057.52 |
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 | $1,057.52 |
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 | $1,057.52 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $1,057.52 |
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 | $1,057.52 |
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 | $1,057.52 |
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 | $1,057.52 |
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 | $1,057.52 |
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 | $1,057.52 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $1,057.52 |
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 | $1,057.52 |
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 | $1,057.52 |
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 | $1,057.52 |
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 | $1,057.52 |
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 | $1,057.52 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $1,057.52 |
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 | $1,057.52 |
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 | $1,057.52 |
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 | $1,046.06 |
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 | $1,046.06 |
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 | $1,046.06 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
CIGNA Medicare Access Plus RX Plan Four (P
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,046.06 |
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 | $1,051.02 |
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 | $1,051.02 |
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 | $1,051.02 |
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 | $1,051.02 |
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 | $1,051.02 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $1,051.02 |
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 | $1,051.02 |
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 | $1,051.02 |
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 | $1,051.02 |
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 | $1,051.02 |
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 | $1,051.02 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $1,051.02 |
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 | $1,051.02 |
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 | $1,051.02 |
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 | $1,051.02 |
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 | $1,051.02 |
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 | $1,051.02 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $1,051.02 |
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 | $1,051.02 |
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 | $1,051.02 |
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 | $1,051.02 |
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 | $1,046.06 |
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 | $1,046.06 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
CIGNA Medicare Access Plus RX Plan Two (PF
|
$22.50 |
$0 |
to be determined |
2 |
Tier 2 |
$35.00 | $87.50 | P | $1,046.06 |
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 | $1,046.06 |
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 | $1,051.02 |
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 | $1,051.02 |
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 | $1,051.02 |
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 | $1,051.02 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $1,051.02 |
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 | $1,051.02 |
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 | $1,051.02 |
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 | $1,051.02 |
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 | $1,051.02 |
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 | $1,051.02 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $1,051.02 |
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 | $1,051.02 |
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 | $1,051.02 |
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 | $1,051.02 |
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 | $1,051.02 |
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 | $1,051.02 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $1,051.02 |
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 | $1,051.02 |
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 | $1,051.02 |
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 | $1,051.02 |
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 | $1,051.02 |
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 | $1,061.93 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $1,061.93 |
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 | $1,061.93 |
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 | $1,061.93 |
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 | $1,061.93 |
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 | $1,061.93 |
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 | $1,061.93 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $1,061.93 |
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 | $1,061.93 |
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 | $1,061.93 |
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 | $1,061.93 |
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 | $1,061.93 |
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 | $1,061.93 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $1,061.93 |
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 | $1,061.93 |
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 | $1,061.93 |
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 | $1,061.93 |
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 | $1,061.93 |
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 | $1,061.93 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $1,061.93 |
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 | $1,061.93 |
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 | $1,061.93 |
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 | $1,061.93 |
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 | $1,061.93 |
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 | $1,061.93 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $1,061.93 |
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 | $1,061.93 |
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 | $1,061.93 |
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 | $1,061.93 |
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 | $1,061.93 |
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 | $1,061.93 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $1,061.93 |
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 | $1,061.93 |
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 | $1,061.93 |
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 | $1,061.93 |
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 | $1,061.93 |
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 | $1,061.93 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $1,061.93 |
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 | $1,061.93 |
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 | $1,061.93 |
Browse Plan Formulary |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
HealthSpring HealthyLiving Preferred (HMO)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,029.82 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-093 (PFFS)
|
$28.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-090 (PFFS)
|
$28.40 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-090 (PFFS)
|
$28.40 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
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 |
Humana Gold Choice H2944-090 (PFFS)
|
$28.40 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-090 (PFFS)
|
$28.40 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-090 (PFFS)
|
$28.40 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-090 (PFFS)
|
$28.40 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-090 (PFFS)
|
$28.40 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-090 (PFFS)
|
$28.40 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
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 |
Humana Gold Choice H2944-090 (PFFS)
|
$28.40 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-090 (PFFS)
|
$28.40 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-090 (PFFS)
|
$28.40 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-090 (PFFS)
|
$28.40 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-090 (PFFS)
|
$28.40 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-090 (PFFS)
|
$28.40 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
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 |
Humana Gold Choice H2944-090 (PFFS)
|
$28.40 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-090 (PFFS)
|
$28.40 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-090 (PFFS)
|
$28.40 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Humana Gold Choice H2944-090 (PFFS)
|
$28.40 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,029.21 |
Browse Plan Formulary |
Windsor Medicare Extra Diabetes Plan (HMO)
|
$28.50 |
$0 |
to be determined |
3 |
Tier 3 |
$25.00 | $75.00 | None | $1,036.23 |
Browse Plan Formulary |
Windsor Medicare Extra Diamond Plan (HMO)
|
$28.50 |
$0 |
to be determined |
3 |
Tier 3 |
$35.00 | $105.00 | None | $1,036.23 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Windsor Medicare Extra Fusion Plan (HMO)
|
$28.50 |
$0 |
to be determined |
3 |
Tier 3 |
$25.00 | $75.00 | None | $1,036.23 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$30.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.34 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$30.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.34 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$30.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.34 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$30.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.34 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$30.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.34 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Sapphire (PPO)
|
$30.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.34 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$30.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.34 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$30.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.34 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$30.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.34 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
15% | 15% | P | $1,028.96 |
Browse Plan Formulary |
AmeriChoice Secure Plus Complete (HMO)
|
$30.70 |
$310 |
to be determined |
2 |
Tier 2 |
n/a | n/a | P | $1,028.98 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Choice H2944-092 (PFFS)
|
$32.30 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,025.74 |
Browse Plan Formulary |
Humana Gold Plus H4461-012 (HMO)
|
$34.00 |
$0 |
to be determined |
3 |
Tier 3 |
$75.00 | $187.50 | P Q:42 /30Days | $1,024.84 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Sapphire (PPO)
|
$35.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.23 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$35.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.23 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$35.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.23 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$35.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.23 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$35.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.23 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$35.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.23 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Sapphire (PPO)
|
$35.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.23 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$35.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.23 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$35.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.23 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$35.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.23 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$35.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.23 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$35.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.23 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Sapphire (PPO)
|
$35.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.23 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$35.00 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.23 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$35.90 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Diamond (PPO)
|
$37.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Ruby (PPO)
|
$37.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option II (PFFS)
|
$39.90 |
$225 |
to be determined |
2 |
Tier 2 |
$34.00 | $68.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Platinum (PFFS)
|
$40.00 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Sapphire (PPO)
|
$40.50 |
$0 |
to be determined |
4 |
Tier 4 |
$65.00 | $162.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,115.33 |
Browse Plan Formulary |
BlueAdvantage Gold (PFFS)
|
$42.40 |
$0 |
to be determined |
4 |
Tier 4 |
$55.00 | $137.50 | P | $1,116.30 |
Browse Plan Formulary |
Plan Name |
Monthly 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 | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.51 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.71 |
Browse Plan Formulary |
Sterling Option IV (PFFS)
|
$44.70 |
$225 |
to be determined |
2 |
Tier 2 |
$36.00 | $72.00 | None | $1,088.78 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
HealthSpring HealthyAdvantage Select (HMO)
|
$45.70 |
$0 |
to be determined |
3 |
Tier 3 |
$40.00 | $120.00 | None | $1,040.71 |
Browse Plan Formulary |
Humana Gold Plus H4461-016 (HMO)
|
$55.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,027.25 |
Browse Plan Formulary |
Humana Gold Plus H4461-016 (HMO)
|
$55.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,027.25 |
Browse Plan Formulary |
Humana Gold Plus H4461-016 (HMO)
|
$55.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,027.25 |
Browse Plan Formulary |
Humana Gold Plus H4461-016 (HMO)
|
$55.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,027.25 |
Browse Plan Formulary |
Plan Name |
Monthly 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 Plus H4461-016 (HMO)
|
$55.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,027.25 |
Browse Plan Formulary |
Humana Gold Plus H4461-016 (HMO)
|
$55.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,027.25 |
Browse Plan Formulary |
Humana Gold Plus H4461-016 (HMO)
|
$55.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,027.25 |
Browse Plan Formulary |
Humana Gold Plus H4461-016 (HMO)
|
$55.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,027.25 |
Browse Plan Formulary |
Humana Gold Plus H4461-016 (HMO)
|
$55.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,027.25 |
Browse Plan Formulary |
Humana Gold Plus H4461-016 (HMO)
|
$55.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,027.25 |
Browse Plan Formulary |
Plan Name |
Monthly 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 Plus H4461-016 (HMO)
|
$55.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,027.25 |
Browse Plan Formulary |
Humana Gold Plus H4461-016 (HMO)
|
$55.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,027.25 |
Browse Plan Formulary |
Humana Gold Plus H4461-016 (HMO)
|
$55.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,027.25 |
Browse Plan Formulary |
Humana Gold Plus H4461-016 (HMO)
|
$55.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,027.25 |
Browse Plan Formulary |
Humana Gold Plus H4461-016 (HMO)
|
$55.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,027.25 |
Browse Plan Formulary |
Humana Gold Plus H4461-016 (HMO)
|
$55.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,027.25 |
Browse Plan Formulary |
Plan Name |
Monthly 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 Plus H4461-016 (HMO)
|
$55.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,027.25 |
Browse Plan Formulary |
Humana Gold Plus H4461-016 (HMO)
|
$55.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,027.25 |
Browse Plan Formulary |
Humana Gold Plus H4461-016 (HMO)
|
$55.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,027.25 |
Browse Plan Formulary |
Humana Gold Plus H4461-016 (HMO)
|
$55.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,027.25 |
Browse Plan Formulary |
Humana Gold Plus H4461-016 (HMO)
|
$55.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,027.25 |
Browse Plan Formulary |
Humana Gold Plus H4461-016 (HMO)
|
$55.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,027.25 |
Browse Plan Formulary |
Plan Name |
Monthly 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 Plus H4461-016 (HMO)
|
$55.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,027.25 |
Browse Plan Formulary |
Humana Gold Plus H4461-016 (HMO)
|
$55.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,027.25 |
Browse Plan Formulary |
Humana Gold Plus H4461-016 (HMO)
|
$55.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,027.25 |
Browse Plan Formulary |
Humana Gold Plus H4461-016 (HMO)
|
$55.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,027.25 |
Browse Plan Formulary |
Humana Gold Plus H4461-016 (HMO)
|
$55.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,027.25 |
Browse Plan Formulary |
Humana Gold Plus H4461-016 (HMO)
|
$55.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | P Q:42 /30Days | $1,027.25 |
Browse Plan Formulary |