2014 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 |
|||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Alamance | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Alexander | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Alleghany | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Anson | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Ashe | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Avery | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Beaufort | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Bertie | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Bladen | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Brunswick | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Buncombe | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Cabarrus | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Caldwell | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Carteret | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Caswell | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Catawba | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Chatham | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Chowan | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Cleveland | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Columbus | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Cumberland | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Davidson | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Davie | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Duplin | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Durham | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Edgecombe | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Forsyth | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Franklin | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Gaston | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Gates | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Granville | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Greene | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Guilford | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Halifax | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Harnett | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Haywood | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Henderson | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Hertford | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Hoke | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Hyde | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Iredell | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Johnston | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Jones | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Lee | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Lincoln | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Madison | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Martin | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
McDowell | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Mecklenburg | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Mitchell | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Montgomery | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Nash | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
New Hanover | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Northampton | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Onslow | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Orange | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Pamlico | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Pender | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Perquimans | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Person | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Pitt | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Polk | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Randolph | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Richmond | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Robeson | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Rockingham | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Rowan | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Sampson | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Scotland | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Stanly | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Stokes | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Surry | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Transylvania | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Tyrrell | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Union | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Vance | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Wake | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Warren | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Washington | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Watauga | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Wayne | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Wilkes | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Wilson | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Yadkin | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: | |||||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Blue Medicare PPO Enhanced (PPO) in NC - H3404-001-0 Benefit Details |
Yancey | $38.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Higher cost-sharing at standard network pharmacies. Details: |
|