Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Adams |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Boone |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Brown |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 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 |
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Bureau |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Cass |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Champaign |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 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 |
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Christian |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Clark |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Coles |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 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 |
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Crawford |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Cumberland |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
De Witt |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 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 |
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
DeKalb |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Douglas |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Edgar |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 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 |
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Effingham |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Ford |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Franklin |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 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 |
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Hancock |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Henry |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Iroquois |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 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 |
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Jackson |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Jasper |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Johnson |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 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 |
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Kankakee |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Knox |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Livingston |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 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 |
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Logan |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Macon |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Macoupin |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 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 |
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Marshall |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Mason |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
McDonough |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 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 |
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
McLean |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Menard |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Mercer |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 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 |
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Montgomery |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Morgan |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Moultrie |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 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 |
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Peoria |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Perry |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Piatt |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 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 |
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Pike |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Putnam |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Rock Island |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 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 |
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Saline |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Sangamon |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Schuyler |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 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 |
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Scott |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Stark |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
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Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Tazewell |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
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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 |
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Vermilion |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Williamson |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Winnebago |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 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 |
Health Alliance Medicare PPO30 Rx (PPO) in IL - H1417-004-0
Benefit Details
|
Woodford |
$79.00 |
$360 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|