2012 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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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Adams | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Alamosa | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Arapahoe | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Archuleta | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Bent | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Boulder | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Broomfield | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Chaffee | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Cheyenne | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Clear Creek | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Conejos | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Costilla | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Crowley | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Custer | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Delta | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Denver | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Dolores | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Douglas | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Eagle | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
El Paso | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Elbert | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Fremont | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Garfield | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Gilpin | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Grand | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Gunnison | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Hinsdale | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Huerfano | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Jackson | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Jefferson | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Kiowa | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Kit Carson | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
La Plata | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Lake | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Larimer | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Las Animas | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Lincoln | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Logan | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Mesa | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Mineral | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Moffat | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Montezuma | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Montrose | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Morgan | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Otero | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Ouray | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Park | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Phillips | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Pitkin | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Prowers | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Pueblo | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Rio Blanco | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Rio Grande | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Routt | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Saguache | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
San Juan | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
San Miguel | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Sedgwick | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Summit | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Teller | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Washington | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Weld | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Yuma | $48.10 | $125 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $13.00 Tier 3: $45.00 Tier 4: $87.00 Tier 5: 30% | $6,700 Browse Formulary | |||||
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