2011 Medicare Part D Contract ID/Plan ID Search
This is archive material for research purposes. Please see
PDPFinder.com or
MAFinder.com for current plans.
Enter a Contract ID and Plan ID
| 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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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details 
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Adair | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Adams | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Allamakee | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Appanoose | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Audubon | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Benton | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Black Hawk | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Boone | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Bremer | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Buchanan | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Buena Vista | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Butler | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Calhoun | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Carroll | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Cass | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Cedar | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Cerro Gordo | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Cherokee | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Chickasaw | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Clarke | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Clay | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Clayton | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Clinton | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Crawford | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Dallas | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Davis | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Decatur | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Delaware | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Des Moines | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Dickinson | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Dubuque | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Emmet | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Fayette | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Floyd | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Franklin | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Fremont | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Greene | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Grundy | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Guthrie | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Hamilton | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Hancock | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Hardin | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Harrison | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Henry | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Howard | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Humboldt | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Ida | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Iowa | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Jackson | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Jasper | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Jefferson | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Johnson | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Jones | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Keokuk | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Kossuth | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Lee | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
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Linn | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Louisa | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Lucas | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Lyon | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Madison | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Mahaska | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Marion | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Marshall | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Mills | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Mitchell | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Monona | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Monroe | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Montgomery | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Muscatine | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
O'Brien | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Osceola | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Page | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Palo Alto | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Plymouth | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Pocahontas | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Polk | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Pottawattamie | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Poweshiek | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Ringgold | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Sac | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Scott | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Shelby | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Sioux | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Statewide | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Story | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Tama | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Taylor | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Union | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Van Buren | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Wapello | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Warren | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Washington | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Wayne | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Webster | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Winnebago | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Winneshiek | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Woodbury | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Worth | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in IA - R5566-005-0 Benefit Details
|
Wright | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Aitkin | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Anoka | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Becker | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Beltrami | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Benton | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Big Stone | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Blue Earth | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Brown | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Carlton | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Carver | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Cass | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Chippewa | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Chisago | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Clay | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Clearwater | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
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Cook | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
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Cottonwood | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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| Service | Exper. | Cost Info | |||||||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
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Crow Wing | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
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Dakota | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
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Dodge | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
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Douglas | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
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Faribault | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
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Fillmore | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
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Freeborn | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
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Goodhue | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
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Grant | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
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Hennepin | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Houston | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Hubbard | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
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Isanti | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
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Itasca | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Jackson | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
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Kanabec | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
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Kandiyohi | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Kittson | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Koochiching | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
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Lac qui Parle | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Lake | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Lake of the Woods | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Le Sueur | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Lincoln | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Lyon | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Mahnomen | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Marshall | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Martin | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
McLeod | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Meeker | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Mille Lacs | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Morrison | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Mower | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Murray | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Nicollet | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Nobles | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Norman | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Olmsted | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Otter Tail | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Pennington | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Pine | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Pipestone | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Polk | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Pope | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Ramsey | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Red Lake | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Redwood | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Renville | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
|
MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Rice | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Rock | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Roseau | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Scott | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Sherburne | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Sibley | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
St. Louis | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Statewide | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Stearns | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Steele | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Stevens | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Swift | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Todd | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Traverse | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Wabasha | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Wadena | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Waseca | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Washington | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Watonwan | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Wilkin | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Winona | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Wright | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MN - R5566-005-0 Benefit Details
|
Yellow Medicine | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Beaverhead | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Big Horn | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Blaine | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Broadwater | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Carbon | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Carter | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Cascade | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Chouteau | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Custer | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Daniels | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Dawson | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Deer Lodge | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Fallon | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Fergus | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Flathead | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Gallatin | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Garfield | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Glacier | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Golden Valley | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Granite | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Hill | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Jefferson | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Judith Basin | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Lake | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Lewis and Clark | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Liberty | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Lincoln | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Madison | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
McCone | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Meagher | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Mineral | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Missoula | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Musselshell | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Park | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Petroleum | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Phillips | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Pondera | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Powder River | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Powell | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Prairie | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Ravalli | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Richland | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Roosevelt | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Rosebud | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Sanders | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Sheridan | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Silver Bow | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Statewide | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Stillwater | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Sweet Grass | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Teton | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Toole | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Treasure | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Valley | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Wheatland | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Wibaux | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Yellowstone | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|||||||||
|
MedicareBlue PPO (Regional PPO) in MT - R5566-005-0 Benefit Details
|
Yellowstone National Park | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Adams | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Antelope | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Arthur | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Banner | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Blaine | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Boone | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Box Butte | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Boyd | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Brown | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Buffalo | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Burt | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Butler | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Cass | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Cedar | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Chase | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Cherry | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Cheyenne | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Clay | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Colfax | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Cuming | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Custer | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Dakota | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Dawes | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Dawson | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Deuel | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Dixon | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Dodge | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Douglas | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Dundy | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Fillmore | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Franklin | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Frontier | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Furnas | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Gage | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Garden | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Garfield | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Gosper | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Grant | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Greeley | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Hall | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Hamilton | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Harlan | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Hayes | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Hitchcock | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Holt | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Hooker | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Howard | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Jefferson | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Johnson | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Kearney | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Keith | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Keya Paha | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Kimball | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Knox | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Lancaster | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Lincoln | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Logan | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Loup | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Madison | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
McPherson | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Merrick | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Morrill | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Nance | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Nemaha | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Nuckolls | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Otoe | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Pawnee | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Perkins | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Phelps | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Pierce | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Platte | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Polk | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Red Willow | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Richardson | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Rock | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Saline | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Sarpy | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Saunders | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Scotts Bluff | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Seward | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Sheridan | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Sherman | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Sioux | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Stanton | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Statewide | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Thayer | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Thomas | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Thurston | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Valley | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Washington | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Wayne | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Webster | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
Wheeler | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in NE - R5566-005-0 Benefit Details
|
York | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Adams | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Barnes | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Benson | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Billings | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Bottineau | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Bowman | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Burke | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Burleigh | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Cass | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Cavalier | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Dickey | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Divide | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Dunn | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Eddy | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Emmons | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Foster | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Golden Valley | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Grand Forks | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Grant | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Griggs | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Hettinger | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Kidder | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
LaMoure | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
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|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Logan | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
McHenry | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
McIntosh | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
McKenzie | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
McLean | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Mercer | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Morton | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Mountrail | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Nelson | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Oliver | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Pembina | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Pierce | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Ramsey | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Ransom | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Renville | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Richland | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Rolette | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Sargent | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Sheridan | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Sioux | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Slope | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Stark | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Statewide | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Steele | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Stutsman | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Towner | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Traill | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Walsh | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Ward | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Wells | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in ND - R5566-005-0 Benefit Details
|
Williams | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Aurora | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Beadle | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Bennett | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Bon Homme | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Brookings | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Brown | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Brule | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Buffalo | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Butte | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Campbell | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Charles Mix | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Clark | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Clay | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Codington | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Corson | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Custer | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Davison | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Day | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Deuel | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Dewey | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Douglas | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Edmunds | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Fall River | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Faulk | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Grant | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Gregory | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Haakon | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Hamlin | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Hand | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Hanson | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Harding | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Hughes | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Hutchinson | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Hyde | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Jackson | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Jerauld | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Jones | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Kingsbury | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Lake | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Lawrence | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Lincoln | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Lyman | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Marshall | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
McCook | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
McPherson | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Meade | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Mellette | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Miner | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Minnehaha | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Moody | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Pennington | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Perkins | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Potter | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Roberts | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Sanborn | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Shannon | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Spink | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Stanley | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Statewide | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Sully | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Todd | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Tripp | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Turner | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Union | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Walworth | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Washabaugh | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Yankton | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
|
|
|
|||||||||
|
MedicareBlue PPO (Regional PPO) in SD - R5566-005-0 Benefit Details
|
Ziebach | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in WY - R5566-005-0 Benefit Details
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Albany | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in WY - R5566-005-0 Benefit Details
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Big Horn | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in WY - R5566-005-0 Benefit Details
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Campbell | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in WY - R5566-005-0 Benefit Details
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Carbon | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in WY - R5566-005-0 Benefit Details
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Converse | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in WY - R5566-005-0 Benefit Details
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Crook | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in WY - R5566-005-0 Benefit Details
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Fremont | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in WY - R5566-005-0 Benefit Details
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Goshen | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in WY - R5566-005-0 Benefit Details
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Hot Springs | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| 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 | |||||||||
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MedicareBlue PPO (Regional PPO) in WY - R5566-005-0 Benefit Details
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Johnson | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in WY - R5566-005-0 Benefit Details
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Laramie | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in WY - R5566-005-0 Benefit Details
|
Lincoln | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
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MedicareBlue PPO (Regional PPO) in WY - R5566-005-0 Benefit Details
|
Natrona | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in WY - R5566-005-0 Benefit Details
|
Niobrara | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in WY - R5566-005-0 Benefit Details
|
Park | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
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MedicareBlue PPO (Regional PPO) in WY - R5566-005-0 Benefit Details
|
Platte | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in WY - R5566-005-0 Benefit Details
|
Sheridan | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in WY - R5566-005-0 Benefit Details
|
Statewide | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
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MedicareBlue PPO (Regional PPO) in WY - R5566-005-0 Benefit Details
|
Sublette | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in WY - R5566-005-0 Benefit Details
|
Sweetwater | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in WY - R5566-005-0 Benefit Details
|
Teton | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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| Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
| Service | Exper. | Cost Info | |||||||||
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MedicareBlue PPO (Regional PPO) in WY - R5566-005-0 Benefit Details
|
Uinta | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in WY - R5566-005-0 Benefit Details
|
Washakie | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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MedicareBlue PPO (Regional PPO) in WY - R5566-005-0 Benefit Details
|
Weston | $71.30 | $310 | No additional gap coverage, only the Donut Hole Discount | Generic Drugs: 13% Preferred Brand Drugs: 26% Non-Preferred Brand Drugs: 50% Specialty Tier Drugs: 25% | $3,350 Browse Formulary | |||||
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Review 2011 Medicare Advantage plans
Chart Legend:
Below are a few notes to help with the understanding of the 2011 Medicare Part D Prescription Drug Plan chart above and Search Tips to help you narrow down your list of plans to those that best meet your needs.
Below are a few notes to help with the understanding of the 2011 Medicare Part D Prescription Drug Plan chart above and Search Tips to help you narrow down your list of plans to those that best meet your needs.
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Q1 Quick Links
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