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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Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Aitkin | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Anoka | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Becker | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Beltrami | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Benton | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Big Stone | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Blue Earth | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Brown | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Carlton | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Carver | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Cass | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Chippewa | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Chisago | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Clay | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Clearwater | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Cook | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Cottonwood | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Crow Wing | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Dakota | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Dodge | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Douglas | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Faribault | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Fillmore | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Freeborn | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Goodhue | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Grant | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Hennepin | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Houston | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Hubbard | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Isanti | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Itasca | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Jackson | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Kanabec | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Kandiyohi | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Kittson | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Koochiching | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Lac qui Parle | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Lake | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Lake of the Woods | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Le Sueur | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Lincoln | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Lyon | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Mahnomen | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Marshall | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Martin | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
McLeod | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Meeker | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Mille Lacs | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Morrison | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Mower | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Murray | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Nicollet | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Nobles | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Norman | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Olmsted | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Otter Tail | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Pennington | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Pine | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Pipestone | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Polk | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Pope | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Ramsey | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Red Lake | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Redwood | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Renville | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Rice | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Rock | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Roseau | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Scott | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Sherburne | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Sibley | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
St. Louis | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Stearns | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Steele | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Stevens | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Swift | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Todd | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Traverse | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Wabasha | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Wadena | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Waseca | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Washington | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Watonwan | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Wilkin | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Winona | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Wright | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in MN - H2450-016-0 Benefit Details |
Yellow Medicine | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Adams | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Barnes | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Bowman | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Burleigh | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Cass | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Cavalier | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Dickey | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Dunn | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Eddy | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Emmons | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Foster | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Grand Forks | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Grant | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Griggs | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Hettinger | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Kidder | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
LaMoure | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Logan | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
McHenry | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
McIntosh | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
McLean | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Mercer | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Morton | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Oliver | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Pembina | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Pierce | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Ransom | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Richland | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Sargent | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Sheridan | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Sioux | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Stark | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Steele | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Stutsman | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Traill | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Walsh | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in ND - H2450-016-0 Benefit Details |
Ward | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Aurora | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Beadle | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Bennett | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Bon Homme | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Brookings | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Brown | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Brule | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Buffalo | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Butte | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Campbell | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Charles Mix | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Clark | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Clay | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Codington | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Custer | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Davison | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Day | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Deuel | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Dewey | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Douglas | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Edmunds | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Fall River | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Grant | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Gregory | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Haakon | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Hamlin | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Hand | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Hanson | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Harding | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Hughes | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Hutchinson | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Jackson | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Jerauld | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Jones | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Kingsbury | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Lake | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Lawrence | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Lincoln | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Lyman | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Marshall | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
McCook | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
McPherson | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Meade | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Mellette | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Miner | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Minnehaha | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Moody | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Pennington | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Perkins | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Roberts | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Sanborn | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Shannon | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Spink | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Stanley | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Todd | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Tripp | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Turner | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Union | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Yankton | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in SD - H2450-016-0 Benefit Details |
Ziebach | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in WI - H2450-016-0 Benefit Details |
Ashland | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in WI - H2450-016-0 Benefit Details |
Barron | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in WI - H2450-016-0 Benefit Details |
Bayfield | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in WI - H2450-016-0 Benefit Details |
Burnett | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in WI - H2450-016-0 Benefit Details |
Chippewa | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in WI - H2450-016-0 Benefit Details |
Douglas | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in WI - H2450-016-0 Benefit Details |
Dunn | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in WI - H2450-016-0 Benefit Details |
Eau Claire | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in WI - H2450-016-0 Benefit Details |
Pierce | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in WI - H2450-016-0 Benefit Details |
Polk | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in WI - H2450-016-0 Benefit Details |
Sawyer | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in WI - H2450-016-0 Benefit Details |
St. Croix | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
Medica Prime Solution Basic with Part D Option 1 (Cost) in WI - H2450-016-0 Benefit Details |
Washburn | $95.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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