Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Alexander |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Alleghany |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Anson |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 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 HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Ashe |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Avery |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Beaufort |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 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 HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Bertie |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Bladen |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Brunswick |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 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 HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Buncombe |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Cabarrus |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Caldwell |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 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 HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Carteret |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Caswell |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Catawba |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 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 HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Chatham |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Chowan |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Cleveland |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 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 HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Columbus |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Cumberland |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Duplin |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 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 HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Durham |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Edgecombe |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Franklin |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 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 HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Gaston |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Gates |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Granville |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 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 HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Greene |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Guilford |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Halifax |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 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 HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Harnett |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Haywood |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Henderson |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 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 HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Hertford |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Hoke |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Hyde |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 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 HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Johnston |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Jones |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Lee |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 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 HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Lincoln |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Madison |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Martin |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 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 HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
McDowell |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Mecklenburg |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Mitchell |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 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 HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Montgomery |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Nash |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
New Hanover |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 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 HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Northampton |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Onslow |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Orange |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 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 HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Pamlico |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Pender |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Perquimans |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 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 HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Person |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Pitt |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Polk |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 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 HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Randolph |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Richmond |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Robeson |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 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 HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Rockingham |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Sampson |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Scotland |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 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 HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Stanly |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Transylvania |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Tyrrell |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 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 HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Union |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Vance |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Warren |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 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 HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Washington |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Watauga |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Wayne |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 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 HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Wilson |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare HMO Standard (HMO) in NC - H3449-013-0
Benefit Details
|
Yancey |
$38.40 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|