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 |
|||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in AR - H5435-014-0 Benefit Details |
Bradley | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in AR - H5435-014-0 Benefit Details |
Hempstead | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in AR - H5435-014-0 Benefit Details |
Nevada | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in AR - H5435-014-0 Benefit Details |
Van Buren | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in CA - H5435-014-0 Benefit Details |
Del Norte | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in CA - H5435-014-0 Benefit Details |
Humboldt | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in CA - H5435-014-0 Benefit Details |
Modoc | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in CA - H5435-014-0 Benefit Details |
Plumas | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in CA - H5435-014-0 Benefit Details |
Siskiyou | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in CA - H5435-014-0 Benefit Details |
Trinity | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Baldwin | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Berrien | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Burke | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Butts | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Calhoun | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Carroll | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Chattooga | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Clay | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Clinch | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Crisp | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Decatur | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Elbert | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Fannin | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Gilmer | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Grady | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Habersham | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Hancock | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Haralson | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Hart | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Heard | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Irwin | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Jefferson | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Lamar | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Lanier | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Lumpkin | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Macon | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
McDuffie | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Meriwether | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Pickens | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Pike | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Quitman | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Randolph | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Schley | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Sumter | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Terrell | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Thomas | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Tift | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Towns | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Troup | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Turner | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Union | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Warren | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in GA - H5435-014-0 Benefit Details |
Washington | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ID - H5435-014-0 Benefit Details |
Blaine | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ID - H5435-014-0 Benefit Details |
Custer | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ID - H5435-014-0 Benefit Details |
Jerome | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ID - H5435-014-0 Benefit Details |
Lemhi | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ID - H5435-014-0 Benefit Details |
Lincoln | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in IA - H5435-014-0 Benefit Details |
Adair | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in IA - H5435-014-0 Benefit Details |
Buena Vista | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in IA - H5435-014-0 Benefit Details |
Calhoun | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in IA - H5435-014-0 Benefit Details |
Cherokee | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in IA - H5435-014-0 Benefit Details |
Clay | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in IA - H5435-014-0 Benefit Details |
Dickinson | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in IA - H5435-014-0 Benefit Details |
Emmet | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in IA - H5435-014-0 Benefit Details |
Humboldt | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in IA - H5435-014-0 Benefit Details |
Ida | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in IA - H5435-014-0 Benefit Details |
Lyon | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in IA - H5435-014-0 Benefit Details |
O'Brien | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in IA - H5435-014-0 Benefit Details |
Osceola | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in IA - H5435-014-0 Benefit Details |
Pocahontas | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in IA - H5435-014-0 Benefit Details |
Ringgold | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in IA - H5435-014-0 Benefit Details |
Sac | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in IA - H5435-014-0 Benefit Details |
Sioux | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in IA - H5435-014-0 Benefit Details |
Union | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in IA - H5435-014-0 Benefit Details |
Webster | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in IA - H5435-014-0 Benefit Details |
Winnebago | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ME - H5435-014-0 Benefit Details |
Washington | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Blaine | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Carter | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Chouteau | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Custer | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Daniels | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Dawson | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Deer Lodge | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Fallon | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Garfield | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Golden Valley | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Hill | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Judith Basin | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Liberty | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Lincoln | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Madison | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
McCone | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Musselshell | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Petroleum | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Phillips | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Pondera | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Powder River | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Prairie | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Richland | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Roosevelt | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Rosebud | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Sheridan | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Silver Bow | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Teton | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Toole | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Treasure | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Valley | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Wheatland | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-014-0 Benefit Details |
Wibaux | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in NH - H5435-014-0 Benefit Details |
Belknap | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in NH - H5435-014-0 Benefit Details |
Cheshire | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in NH - H5435-014-0 Benefit Details |
Coos | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in NH - H5435-014-0 Benefit Details |
Grafton | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in NH - H5435-014-0 Benefit Details |
Merrimack | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in NH - H5435-014-0 Benefit Details |
Strafford | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in NH - H5435-014-0 Benefit Details |
Sullivan | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ND - H5435-014-0 Benefit Details |
Adams | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ND - H5435-014-0 Benefit Details |
Benson | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ND - H5435-014-0 Benefit Details |
Billings | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ND - H5435-014-0 Benefit Details |
Bottineau | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ND - H5435-014-0 Benefit Details |
Bowman | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ND - H5435-014-0 Benefit Details |
Burke | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ND - H5435-014-0 Benefit Details |
Divide | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ND - H5435-014-0 Benefit Details |
Dunn | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ND - H5435-014-0 Benefit Details |
Golden Valley | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ND - H5435-014-0 Benefit Details |
Grant | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ND - H5435-014-0 Benefit Details |
Hettinger | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ND - H5435-014-0 Benefit Details |
McHenry | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ND - H5435-014-0 Benefit Details |
McKenzie | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ND - H5435-014-0 Benefit Details |
McLean | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ND - H5435-014-0 Benefit Details |
Mercer | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ND - H5435-014-0 Benefit Details |
Mountrail | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ND - H5435-014-0 Benefit Details |
Nelson | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ND - H5435-014-0 Benefit Details |
Pierce | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ND - H5435-014-0 Benefit Details |
Ramsey | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ND - H5435-014-0 Benefit Details |
Renville | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ND - H5435-014-0 Benefit Details |
Rolette | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ND - H5435-014-0 Benefit Details |
Sheridan | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ND - H5435-014-0 Benefit Details |
Slope | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ND - H5435-014-0 Benefit Details |
Stark | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ND - H5435-014-0 Benefit Details |
Towner | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ND - H5435-014-0 Benefit Details |
Ward | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ND - H5435-014-0 Benefit Details |
Wells | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in ND - H5435-014-0 Benefit Details |
Williams | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in SD - H5435-014-0 Benefit Details |
Bennett | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in SD - H5435-014-0 Benefit Details |
Corson | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in SD - H5435-014-0 Benefit Details |
Dewey | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in SD - H5435-014-0 Benefit Details |
Faulk | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in SD - H5435-014-0 Benefit Details |
Haakon | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in SD - H5435-014-0 Benefit Details |
Harding | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in SD - H5435-014-0 Benefit Details |
Hyde | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in SD - H5435-014-0 Benefit Details |
Jackson | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in SD - H5435-014-0 Benefit Details |
Jones | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in SD - H5435-014-0 Benefit Details |
Mellette | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in SD - H5435-014-0 Benefit Details |
Pennington | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in SD - H5435-014-0 Benefit Details |
Perkins | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in SD - H5435-014-0 Benefit Details |
Potter | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in SD - H5435-014-0 Benefit Details |
Shannon | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in SD - H5435-014-0 Benefit Details |
Sully | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in SD - H5435-014-0 Benefit Details |
Todd | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in SD - H5435-014-0 Benefit Details |
Walworth | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in SD - H5435-014-0 Benefit Details |
Ziebach | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Blanco | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Brewster | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Brooks | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Brown | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Calhoun | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Colorado | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Comanche | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Crane | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Culberson | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Delta | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
DeWitt | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Duval | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Eastland | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Erath | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Frio | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Gillespie | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Goliad | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Gonzales | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Hudspeth | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Jack | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Jackson | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Jeff Davis | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Karnes | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Kenedy | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Kerr | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
La Salle | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Lavaca | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Live Oak | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Loving | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Matagorda | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Maverick | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
McMullen | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Pecos | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Presidio | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Rains | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Real | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Reeves | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Refugio | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Somervell | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Terrell | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Uvalde | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Victoria | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Ward | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Wharton | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Winkler | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in TX - H5435-014-0 Benefit Details |
Wise | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in VA - H5435-014-0 Benefit Details |
Amherst | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in VA - H5435-014-0 Benefit Details |
Augusta | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in VA - H5435-014-0 Benefit Details |
Brunswick | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in VA - H5435-014-0 Benefit Details |
Buena Vista City | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in VA - H5435-014-0 Benefit Details |
Campbell | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in VA - H5435-014-0 Benefit Details |
Carroll | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in VA - H5435-014-0 Benefit Details |
Culpeper | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in VA - H5435-014-0 Benefit Details |
Danville City | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in VA - H5435-014-0 Benefit Details |
Emporia City | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in VA - H5435-014-0 Benefit Details |
Fauquier | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in VA - H5435-014-0 Benefit Details |
Galax City | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in VA - H5435-014-0 Benefit Details |
Greensville | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in VA - H5435-014-0 Benefit Details |
Halifax | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in VA - H5435-014-0 Benefit Details |
Harrisonburg City | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in VA - H5435-014-0 Benefit Details |
Henry | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in VA - H5435-014-0 Benefit Details |
Lynchburg City | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in VA - H5435-014-0 Benefit Details |
Martinsville City | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in VA - H5435-014-0 Benefit Details |
Mecklenburg | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in VA - H5435-014-0 Benefit Details |
Patrick | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in VA - H5435-014-0 Benefit Details |
Pittsylvania | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in VA - H5435-014-0 Benefit Details |
Rockbridge | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in VA - H5435-014-0 Benefit Details |
Rockingham | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in VA - H5435-014-0 Benefit Details |
Spotsylvania | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
UnitedHealthcare MedicareDirect Rx (PFFS) in VA - H5435-014-0 Benefit Details |
Staunton City | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareDirect Rx (PFFS) in VA - H5435-014-0 Benefit Details |
Waynesboro City | $28.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $45.00 Tier 4: $93.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
|