ROCEPHIN 2GM/DEXTROSE 2.4% (NDC: 00004200378)
2010 Medicare Prescription Drug Plan (MAPD) Information
Click here for the Chart Legend |
Plan Name |
Monthly Prem. |
De- duct- ible |
Does Plan Offer Gap Coverage |
Drug Tier Information |
Cost-Sharing |
Drug Usage Mgmt |
Plan’s Avg. Retail Drug Price 30-Day |
Tier Nbr. |
Tier Desc. |
30-Day Prfrd. Pharm |
90-Day Mail Order |
AARP MedicareComplete Plan 1 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | None | $1,463.46 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | None | $1,463.46 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | None | $1,463.46 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | None | $1,463.46 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | None | $1,463.46 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | None | $1,463.46 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | None | $1,463.46 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | None | $1,463.46 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | None | $1,463.46 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | None | $1,463.46 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | None | $1,463.46 |
Browse Plan Formulary |
|
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | None | $1,463.46 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | None | $1,463.46 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | None | $1,463.46 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | None | $1,463.46 |
Browse Plan Formulary |
AARP MedicareComplete Plan 2 (HMO)
|
$0.00 |
$0 |
to be determined |
3 |
Tier 3 |
$79.00 | $227.00 | None | $1,463.46 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
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 |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
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 |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
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 |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
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 |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
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 |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
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 |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
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 |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
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 |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
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 |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
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 |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
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 |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Plus (PPO)
|
$17.70 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
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 |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
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 H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
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 H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
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 H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-112 (PFFS)
|
$19.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
SecurityChoice Plus (PFFS)
|
$22.10 |
$0 |
to be determined |
5 |
Tier 5 |
33% | n/a | None | $1,274.92 |
Browse Plan Formulary |
Plan Name |
Monthly Prem. |
De- duct- ible |
Gap Coverage |
Tier Nbr. |
Tier Desc. |
30-Day Prfd. Pharm |
90-Day Mail Order |
Drug Usage Mgmt |
Retail Drug Price |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
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 H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
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 H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
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 H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-108 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-110 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-110 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
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 H2944-110 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-110 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-110 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-110 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-110 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-110 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
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 H2944-110 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-110 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-110 (PFFS)
|
$23.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
HumanaChoice H5214-009 (PPO)
|
$24.90 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-109 (PFFS)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-109 (PFFS)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
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 H2944-109 (PFFS)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-109 (PFFS)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-109 (PFFS)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-109 (PFFS)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-109 (PFFS)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-109 (PFFS)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
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 H2944-109 (PFFS)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-109 (PFFS)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-109 (PFFS)
|
$26.00 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
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 H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
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 H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
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 H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
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 H2944-107 (PFFS)
|
$27.50 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
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 H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
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 H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
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 H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Humana Gold Choice H2944-111 (PFFS)
|
$27.70 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
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 |
HumanaChoice H5214-010 (PPO)
|
$31.90 |
$0 |
to be determined |
3 |
Tier 3 |
$80.00 | $200.00 | None | $1,864.98 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
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 |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
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 |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
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 |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
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 |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
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 |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
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 |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
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 |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
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 |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
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 |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
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 |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
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 |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
Blue Advantage Preferred (PPO)
|
$34.30 |
$0 |
to be determined |
4 |
Tier 4 |
$60.00 | $180.00 | None | $1,468.17 |
Browse Plan Formulary |
HumanaChoice R5826-001 (Regional PPO)
|
$36.20 |
$310 |
to be determined |
3 |
Tier 3 |
25% | 25% | None | $1,864.98 |
Browse Plan Formulary |