Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Adams |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
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|
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Alamosa |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Arapahoe |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
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|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Archuleta |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Bent |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Boulder |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Broomfield |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Chaffee |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Cheyenne |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
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|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Clear Creek |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Conejos |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Costilla |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Crowley |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Custer |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Delta |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Denver |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Dolores |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Douglas |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Eagle |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
El Paso |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Elbert |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Fremont |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Garfield |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Gilpin |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Grand |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Gunnison |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Hinsdale |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Huerfano |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Jackson |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Jefferson |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Kiowa |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Kit Carson |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
La Plata |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Lake |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Larimer |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Las Animas |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Lincoln |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Logan |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
|
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Mesa |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Mineral |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
|
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Moffat |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
|
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Montezuma |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Montrose |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
|
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Morgan |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
|
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Otero |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Ouray |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
|
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Park |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
|
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Phillips |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Pitkin |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
|
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Prowers |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
|
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Pueblo |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Rio Blanco |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
|
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Rio Grande |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
|
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Routt |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Saguache |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
-- |
|
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
San Juan |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
San Miguel |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Sedgwick |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Summit |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Teller |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
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|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Washington |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Weld |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
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Rocky Mountain Plus Plan + Rx (Cost) in CO - H0602-019-0
Benefit Details
|
Yuma |
$280.70 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Non-Preferred Generic: $25.00 Preferred Brand: $40.00 Non-Preferred Brand: $60.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
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