2011 Medicare Advantage Plan Information Click here to jump to the Chart Legend & Search Tips | |||||||||||
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Plan Name | County | Monthly Prem. (Parts C & D) |
Deduct- ible |
(Donut Hole) Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance 30-Day Supply |
MOOP for Part A & B Benefits | |||||
Cust. Service Rating |
Member Plan Exper. |
RxCost Info Rating |
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Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Adams | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Barnes | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Bowman | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Burleigh | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Cass | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Cavalier | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Dickey | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Dunn | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Eddy | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Emmons | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Foster | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Grand Forks | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Grant | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Griggs | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Hettinger | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Kidder | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
LaMoure | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Logan | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
McHenry | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
McIntosh | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
McLean | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Mercer | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Morton | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Oliver | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Pembina | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Pierce | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Ransom | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Richland | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Sargent | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Sheridan | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Sioux | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Stark | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Steele | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Stutsman | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Traill | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Walsh | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in ND - H2450-012-0 Benefit Details |
Ward | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Aurora | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Beadle | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Bennett | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Bon Homme | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Brookings | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Brown | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Brule | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Buffalo | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Butte | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Campbell | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Charles Mix | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Clark | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Clay | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Codington | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Custer | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Davison | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Day | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Deuel | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Dewey | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Douglas | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Edmunds | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Fall River | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Grant | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Gregory | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Haakon | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Hamlin | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Hand | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Hanson | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Harding | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Hughes | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Hutchinson | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Jackson | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Jerauld | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Jones | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Kingsbury | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Lake | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Lawrence | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Lincoln | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Lyman | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Marshall | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
McCook | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
McPherson | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Meade | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Mellette | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Miner | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Minnehaha | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Moody | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Pennington | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Perkins | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Roberts | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Sanborn | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Shannon | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Spink | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Stanley | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Todd | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Tripp | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Turner | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Union | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Yankton | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic w/Standard Rx - ND/SD (Cost) in SD - H2450-012-0 Benefit Details |
Ziebach | $122.30 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: $10.00 Preferred Brand Drugs: $34.00 Non-Preferred Brand Drugs: $74.00 Specialty Tier Drugs: 25% | $3,000 Browse Formulary | |||||
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