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 |
|||||||||
Any, Any, Any Gold (PFFS) in AZ - H8098-001-0 Benefit Details |
Maricopa | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in AZ - H8098-001-0 Benefit Details |
Pima | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
Alachua | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
Brevard | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
Broward | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
Charlotte | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
Citrus | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
Clay | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
Collier | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
Duval | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
Hernando | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
Hillsborough | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
Indian River | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
Lee | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
Leon | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
Manatee | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
Marion | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
Martin | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
Miami-Dade | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
Orange | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
Osceola | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
Palm Beach | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
Pasco | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
Pinellas | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
Polk | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
Putnam | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
Santa Rosa | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
Sarasota | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
Seminole | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
St. Lucie | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
Sumter | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in FL - H8098-001-0 Benefit Details |
Volusia | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in GA - H8098-001-0 Benefit Details |
Chatham | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in GA - H8098-001-0 Benefit Details |
Clayton | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in GA - H8098-001-0 Benefit Details |
Cobb | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in GA - H8098-001-0 Benefit Details |
Columbia | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in GA - H8098-001-0 Benefit Details |
DeKalb | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in GA - H8098-001-0 Benefit Details |
Fulton | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in GA - H8098-001-0 Benefit Details |
Gwinnett | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in GA - H8098-001-0 Benefit Details |
Henry | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in GA - H8098-001-0 Benefit Details |
Richmond | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in GA - H8098-001-0 Benefit Details |
Rockdale | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in LA - H8098-001-0 Benefit Details |
Bossier | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in LA - H8098-001-0 Benefit Details |
Caddo | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in LA - H8098-001-0 Benefit Details |
East Baton Rouge | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in LA - H8098-001-0 Benefit Details |
Lafayette | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in LA - H8098-001-0 Benefit Details |
Ouachita | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in LA - H8098-001-0 Benefit Details |
Rapides | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in MD - H8098-001-0 Benefit Details |
Anne Arundel | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in MD - H8098-001-0 Benefit Details |
Baltimore | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in MD - H8098-001-0 Benefit Details |
Baltimore City | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in MD - H8098-001-0 Benefit Details |
Howard | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in MD - H8098-001-0 Benefit Details |
Montgomery | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in MD - H8098-001-0 Benefit Details |
Prince George's | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in MO - H8098-001-0 Benefit Details |
Jackson | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in MO - H8098-001-0 Benefit Details |
St. Louis | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in MO - H8098-001-0 Benefit Details |
St. Louis City | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in NV - H8098-001-0 Benefit Details |
Clark | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in NV - H8098-001-0 Benefit Details |
Washoe | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in NY - H8098-001-0 Benefit Details |
New York | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in NC - H8098-001-0 Benefit Details |
Davidson | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in NC - H8098-001-0 Benefit Details |
Forsyth | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in NC - H8098-001-0 Benefit Details |
Guilford | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in NC - H8098-001-0 Benefit Details |
Mecklenburg | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in OH - H8098-001-0 Benefit Details |
Butler | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in OH - H8098-001-0 Benefit Details |
Franklin | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in OH - H8098-001-0 Benefit Details |
Hamilton | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in OH - H8098-001-0 Benefit Details |
Lucas | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in OH - H8098-001-0 Benefit Details |
Mahoning | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in OH - H8098-001-0 Benefit Details |
Montgomery | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in OH - H8098-001-0 Benefit Details |
Stark | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in PA - H8098-001-0 Benefit Details |
Allegheny | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in PA - H8098-001-0 Benefit Details |
Beaver | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in PA - H8098-001-0 Benefit Details |
Berks | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in PA - H8098-001-0 Benefit Details |
Bucks | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in PA - H8098-001-0 Benefit Details |
Butler | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in PA - H8098-001-0 Benefit Details |
Carbon | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in PA - H8098-001-0 Benefit Details |
Dauphin | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in PA - H8098-001-0 Benefit Details |
Delaware | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in PA - H8098-001-0 Benefit Details |
Erie | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in PA - H8098-001-0 Benefit Details |
Lehigh | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in PA - H8098-001-0 Benefit Details |
Luzerne | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in PA - H8098-001-0 Benefit Details |
Mercer | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in PA - H8098-001-0 Benefit Details |
Montgomery | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in PA - H8098-001-0 Benefit Details |
Northampton | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in PA - H8098-001-0 Benefit Details |
Philadelphia | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in PA - H8098-001-0 Benefit Details |
Schuylkill | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in PA - H8098-001-0 Benefit Details |
Washington | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in PA - H8098-001-0 Benefit Details |
Westmoreland | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in SC - H8098-001-0 Benefit Details |
Aiken | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in SC - H8098-001-0 Benefit Details |
Beaufort | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in SC - H8098-001-0 Benefit Details |
Berkeley | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in SC - H8098-001-0 Benefit Details |
Charleston | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in SC - H8098-001-0 Benefit Details |
Greenville | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in SC - H8098-001-0 Benefit Details |
Pickens | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in SC - H8098-001-0 Benefit Details |
Spartanburg | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in SC - H8098-001-0 Benefit Details |
York | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in TX - H8098-001-0 Benefit Details |
Bexar | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in TX - H8098-001-0 Benefit Details |
Collin | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in TX - H8098-001-0 Benefit Details |
Dallas | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in TX - H8098-001-0 Benefit Details |
Denton | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in TX - H8098-001-0 Benefit Details |
El Paso | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in TX - H8098-001-0 Benefit Details |
Fort Bend | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in TX - H8098-001-0 Benefit Details |
Harris | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in TX - H8098-001-0 Benefit Details |
Hidalgo | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in TX - H8098-001-0 Benefit Details |
Montgomery | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in TX - H8098-001-0 Benefit Details |
Potter | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in TX - H8098-001-0 Benefit Details |
Randall | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in TX - H8098-001-0 Benefit Details |
Tarrant | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in TX - H8098-001-0 Benefit Details |
Taylor | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in TX - H8098-001-0 Benefit Details |
Travis | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in TX - H8098-001-0 Benefit Details |
Williamson | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in UT - H8098-001-0 Benefit Details |
Davis | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in UT - H8098-001-0 Benefit Details |
Salt Lake | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in UT - H8098-001-0 Benefit Details |
Utah | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in UT - H8098-001-0 Benefit Details |
Washington | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in UT - H8098-001-0 Benefit Details |
Weber | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in VA - H8098-001-0 Benefit Details |
Chesterfield | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in VA - H8098-001-0 Benefit Details |
Fairfax | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in VA - H8098-001-0 Benefit Details |
Henrico | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 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 | |||||||||
Any, Any, Any Gold (PFFS) in VA - H8098-001-0 Benefit Details |
Richmond City | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- | ||||||||||
Any, Any, Any Gold (PFFS) in DC - H8098-001-0 Benefit Details |
District of Columbia | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
-- | -- |
|