2013 Medicare Advantage Plan Information Click here to jump to the Chart Legend & Search Tips | |||||||||||
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Plan Name | County | Monthly Prem. (Parts C & D) |
Deduct- ible |
(Donut Hole) Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance 30-Day Supply |
MOOP for Part A & B Benefits | |||||
Cust. Service Rating |
Member Plan Exper. |
RxCost Info Rating |
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Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Adams | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Alamosa | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Arapahoe | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Archuleta | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Bent | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Boulder | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Broomfield | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Chaffee | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Cheyenne | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Clear Creek | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Conejos | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Costilla | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Crowley | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Custer | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Delta | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Denver | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Dolores | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Douglas | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Eagle | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
El Paso | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Elbert | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Fremont | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Garfield | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Gilpin | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Grand | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Gunnison | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Hinsdale | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Huerfano | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Jackson | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Jefferson | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Kiowa | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Kit Carson | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
La Plata | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Lake | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Larimer | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Las Animas | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Lincoln | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Logan | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Mesa | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Mineral | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Moffat | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Montezuma | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Montrose | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Morgan | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Otero | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Ouray | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Park | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Phillips | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Pitkin | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Prowers | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Pueblo | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Rio Blanco | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Rio Grande | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Routt | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Saguache | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
San Juan | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
San Miguel | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Sedgwick | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Summit | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Teller | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $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 | |||||||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Washington | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Weld | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
Rocky Mountain Green Plan + Rx (Cost) in CO - H0602-043-0 Benefit Details |
Yuma | $56.00 | $125 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Non-Preferred Generic: $13.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 30% | $6,700 Browse Formulary | |||||
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