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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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Aitkin | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Anoka | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Becker | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 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 | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Beltrami | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Benton | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Big Stone | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 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 | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Blue Earth | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Brown | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Carlton | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 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 | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Carver | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Cass | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Chippewa | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 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 | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Chisago | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Clay | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Clearwater | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 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 | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Cook | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Cottonwood | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Crow Wing | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 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 | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Dakota | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Dodge | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Douglas | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 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 | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Faribault | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Fillmore | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Freeborn | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 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 | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Goodhue | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Grant | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Hennepin | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 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 | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Houston | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Hubbard | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Isanti | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 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 | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Itasca | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Jackson | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Kanabec | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 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 | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Kandiyohi | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Kittson | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Koochiching | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 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 | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Lac qui Parle | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Lake | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Lake of the Woods | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 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 | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Le Sueur | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Lincoln | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Lyon | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 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 | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Mahnomen | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Marshall | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Martin | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 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 | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
McLeod | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Meeker | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Mille Lacs | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 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 | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Morrison | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Mower | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Murray | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 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 | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Nicollet | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Nobles | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Norman | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 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 | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Olmsted | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Otter Tail | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Pennington | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 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 | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Pine | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Pipestone | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Polk | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 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 | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Pope | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Ramsey | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Red Lake | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 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 | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Redwood | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Renville | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Rice | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Rock | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Roseau | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Scott | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Sherburne | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Sibley | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
St. Louis | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Stearns | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Steele | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Stevens | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Swift | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Todd | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Traverse | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Wabasha | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Wadena | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Waseca | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Washington | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Watonwan | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Wilkin | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Winona | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Wright | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in MN - H2450-017-0 Benefit Details |
Yellow Medicine | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Adams | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Barnes | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Bowman | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Burleigh | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Cass | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Cavalier | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Dickey | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Dunn | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Eddy | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Emmons | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Foster | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Grand Forks | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Grant | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Griggs | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Hettinger | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Kidder | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
LaMoure | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Logan | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
McHenry | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
McIntosh | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
McLean | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Mercer | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Morton | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Oliver | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Pembina | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Pierce | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Ransom | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Richland | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Sargent | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Sheridan | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Sioux | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Stark | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Steele | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Stutsman | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Traill | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Walsh | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in ND - H2450-017-0 Benefit Details |
Ward | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Aurora | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Beadle | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Bennett | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Bon Homme | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Brookings | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Brown | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Brule | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Buffalo | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Butte | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Campbell | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Charles Mix | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Clark | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Clay | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Codington | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Custer | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Davison | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Day | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Deuel | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Dewey | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Douglas | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Edmunds | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Fall River | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Grant | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Gregory | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Haakon | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Hamlin | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Hand | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Hanson | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Harding | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Hughes | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Hutchinson | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Jackson | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Jerauld | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Jones | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Kingsbury | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Lake | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Lawrence | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Lincoln | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Lyman | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Marshall | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
McCook | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
McPherson | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Meade | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Mellette | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Miner | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Minnehaha | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Moody | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Pennington | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Perkins | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Roberts | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Sanborn | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Shannon | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Spink | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Stanley | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Todd | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Tripp | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Turner | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Union | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Yankton | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in SD - H2450-017-0 Benefit Details |
Ziebach | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in WI - H2450-017-0 Benefit Details |
Ashland | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in WI - H2450-017-0 Benefit Details |
Barron | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in WI - H2450-017-0 Benefit Details |
Bayfield | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in WI - H2450-017-0 Benefit Details |
Burnett | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in WI - H2450-017-0 Benefit Details |
Chippewa | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in WI - H2450-017-0 Benefit Details |
Douglas | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in WI - H2450-017-0 Benefit Details |
Dunn | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in WI - H2450-017-0 Benefit Details |
Eau Claire | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in WI - H2450-017-0 Benefit Details |
Pierce | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in WI - H2450-017-0 Benefit Details |
Polk | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in WI - H2450-017-0 Benefit Details |
Sawyer | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in WI - H2450-017-0 Benefit Details |
St. Croix | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) in WI - H2450-017-0 Benefit Details |
Washburn | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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