Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Adams |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Alamosa |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Arapahoe |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 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 Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Archuleta |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Bent |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Boulder |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 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 Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Broomfield |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Chaffee |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Cheyenne |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 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 Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Clear Creek |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Conejos |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Costilla |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 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 Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Crowley |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Custer |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Delta |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 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 Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Denver |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Dolores |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Douglas |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 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 Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Eagle |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Elbert |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
El Paso |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 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 Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Fremont |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Garfield |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Gilpin |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 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 Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Grand |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Gunnison |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Hinsdale |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 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 Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Huerfano |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Jackson |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Jefferson |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 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 Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Kiowa |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Kit Carson |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Lake |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 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 Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
La Plata |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Larimer |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Las Animas |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 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 Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Lincoln |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Logan |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Mesa |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 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 Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Mineral |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Moffat |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Montezuma |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 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 Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Montrose |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Morgan |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Otero |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 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 Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Ouray |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Park |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Phillips |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 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 Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Pitkin |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Prowers |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Pueblo |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 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 Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Rio Blanco |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Rio Grande |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Routt |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 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 Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Saguache |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
San Juan |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
San Miguel |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 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 Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Sedgwick |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Summit |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Teller |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 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 Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Washington |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Weld |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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|
|
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Rocky Mountain Thrifty Plan + Rx (Cost) in CO - H0602-039-0
Benefit Details
|
Yuma |
$123.30 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 26%
| $6,700 Browse Formulary |
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