2012 Medicare Advantage Plan Information Click here to jump to the Chart Legend & Search Tips | |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
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 |
|||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Aitkin | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Anoka | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Becker | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Beltrami | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Benton | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Big Stone | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Blue Earth | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Brown | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Carlton | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Carver | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Cass | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Chippewa | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Chisago | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Clay | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Clearwater | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Cook | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Cottonwood | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Crow Wing | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Dakota | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Dodge | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Douglas | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Faribault | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Fillmore | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Freeborn | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Goodhue | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Grant | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Hennepin | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Houston | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Hubbard | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Isanti | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Itasca | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Jackson | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Kanabec | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Kandiyohi | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Kittson | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Koochiching | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Lac qui Parle | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Lake | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Lake of the Woods | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Le Sueur | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Lincoln | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Lyon | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Mahnomen | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Marshall | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Martin | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
McLeod | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Meeker | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Mille Lacs | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Morrison | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Mower | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Murray | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Nicollet | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Nobles | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Norman | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Olmsted | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Otter Tail | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Pennington | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Pine | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Pipestone | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Polk | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Pope | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Ramsey | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Red Lake | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Redwood | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Renville | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Rice | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Rock | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Roseau | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Scott | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Sherburne | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Sibley | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
St. Louis | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Stearns | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Steele | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Stevens | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Swift | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Todd | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Traverse | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Wabasha | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Wadena | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Waseca | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Washington | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Watonwan | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Wilkin | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Winona | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Wright | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in MN - H2450-028-0 Benefit Details |
Yellow Medicine | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Adams | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Barnes | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Bowman | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Burleigh | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Cass | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Cavalier | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Dickey | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Dunn | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Eddy | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Emmons | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Foster | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Grand Forks | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Grant | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Griggs | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Hettinger | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Kidder | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
LaMoure | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Logan | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
McHenry | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
McIntosh | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
McLean | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Mercer | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Morton | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Oliver | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Pembina | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Pierce | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Ransom | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Richland | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Sargent | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Sheridan | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Sioux | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Stark | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Steele | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Stutsman | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Traill | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Walsh | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in ND - H2450-028-0 Benefit Details |
Ward | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Aurora | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Beadle | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Bennett | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Bon Homme | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Brookings | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Brown | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Brule | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Buffalo | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Butte | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Campbell | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Charles Mix | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Clark | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Clay | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Codington | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Custer | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Davison | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Day | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Deuel | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Dewey | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Douglas | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Edmunds | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Fall River | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Grant | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Gregory | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Haakon | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Hamlin | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Hand | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Hanson | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Harding | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Hughes | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Hutchinson | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Jackson | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Jerauld | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Jones | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Kingsbury | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Lake | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Lawrence | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Lincoln | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Lyman | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Marshall | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
McCook | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
McPherson | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Meade | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Mellette | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Miner | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Minnehaha | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Moody | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Pennington | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Perkins | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Roberts | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Sanborn | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Shannon | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Spink | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Stanley | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Todd | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Tripp | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Turner | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Union | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Yankton | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in SD - H2450-028-0 Benefit Details |
Ziebach | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in WI - H2450-028-0 Benefit Details |
Ashland | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in WI - H2450-028-0 Benefit Details |
Barron | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in WI - H2450-028-0 Benefit Details |
Bayfield | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in WI - H2450-028-0 Benefit Details |
Burnett | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in WI - H2450-028-0 Benefit Details |
Chippewa | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in WI - H2450-028-0 Benefit Details |
Douglas | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in WI - H2450-028-0 Benefit Details |
Dunn | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in WI - H2450-028-0 Benefit Details |
Eau Claire | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in WI - H2450-028-0 Benefit Details |
Pierce | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in WI - H2450-028-0 Benefit Details |
Polk | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in WI - H2450-028-0 Benefit Details |
Sawyer | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in WI - H2450-028-0 Benefit Details |
St. Croix | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- | |||||||||||
Medica Prime Solution Value with Part D Option 3 (Cost) in WI - H2450-028-0 Benefit Details |
Washburn | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
-- |
|