Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Aitkin |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
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Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Anoka |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
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|
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Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Becker |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Beltrami |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
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Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Benton |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
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Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Big Stone |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Blue Earth |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
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|
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Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Brown |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
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|
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Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Carlton |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Carver |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
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Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Cass |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
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Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Chippewa |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Chisago |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
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Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Clay |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
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Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Clearwater |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Cook |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
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Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Cottonwood |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
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Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Crow Wing |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Dakota |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
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Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Dodge |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
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|
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Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Douglas |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Faribault |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
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|
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Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Fillmore |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
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|
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Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Freeborn |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Goodhue |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
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|
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Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Grant |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
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|
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Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Hennepin |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Houston |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Hubbard |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Isanti |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Itasca |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Jackson |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Kanabec |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Kandiyohi |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Kittson |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Koochiching |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Lac qui Parle |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Lake |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Lake of the Woods |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Le Sueur |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Lincoln |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Lyon |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
McLeod |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Mahnomen |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Marshall |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Martin |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Meeker |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Mille Lacs |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Morrison |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Mower |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Murray |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Nicollet |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Nobles |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Norman |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Olmsted |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
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|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Otter Tail |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Pennington |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Pine |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Pipestone |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Polk |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Pope |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Ramsey |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Red Lake |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Redwood |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Renville |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Rice |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Rock |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Roseau |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
St. Louis |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Scott |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Sherburne |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Sibley |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Stearns |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Steele |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Stevens |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Swift |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Todd |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Traverse |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Wabasha |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Wadena |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Waseca |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Washington |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Watonwan |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Wilkin |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Winona |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Wright |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in MN - H2450-023-0
Benefit Details
|
Yellow Medicine |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Adams |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Barnes |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Benson |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Billings |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Bowman |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Burleigh |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Cass |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Cavalier |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Dickey |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Dunn |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Eddy |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Emmons |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Foster |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Grand Forks |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Grant |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Griggs |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Hettinger |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Kidder |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
LaMoure |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Logan |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
McHenry |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
McIntosh |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
McLean |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Mercer |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Morton |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Nelson |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Oliver |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Pembina |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Pierce |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Ramsey |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Ransom |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Richland |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Rolette |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Sargent |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Sheridan |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Sioux |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Slope |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Stark |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Steele |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Stutsman |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Towner |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Traill |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Walsh |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Ward |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Wells |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in ND - H2450-023-0
Benefit Details
|
Williams |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Aurora |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Beadle |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Bennett |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Bon Homme |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Brookings |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Brown |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Brule |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Buffalo |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Butte |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Campbell |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Charles Mix |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Clark |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Clay |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Codington |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Corson |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Custer |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Davison |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Day |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Deuel |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Dewey |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Douglas |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Edmunds |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Fall River |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Faulk |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Grant |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Gregory |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Haakon |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Hamlin |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Hand |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Hanson |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Harding |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Hughes |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Hutchinson |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Jackson |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Jerauld |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Jones |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Kingsbury |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Lake |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Lawrence |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Lincoln |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Lyman |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
McCook |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
McPherson |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Marshall |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Meade |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Mellette |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Miner |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Minnehaha |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Moody |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Pennington |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Perkins |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Potter |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Roberts |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Sanborn |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Oglala Lakota |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Spink |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Stanley |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Sully |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Todd |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Tripp |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Turner |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Union |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Walworth |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Yankton |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in SD - H2450-023-0
Benefit Details
|
Ziebach |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in WI - H2450-023-0
Benefit Details
|
Ashland |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in WI - H2450-023-0
Benefit Details
|
Barron |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in WI - H2450-023-0
Benefit Details
|
Bayfield |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in WI - H2450-023-0
Benefit Details
|
Burnett |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in WI - H2450-023-0
Benefit Details
|
Chippewa |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in WI - H2450-023-0
Benefit Details
|
Douglas |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in WI - H2450-023-0
Benefit Details
|
Dunn |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in WI - H2450-023-0
Benefit Details
|
Eau Claire |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in WI - H2450-023-0
Benefit Details
|
Pierce |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in WI - H2450-023-0
Benefit Details
|
Polk |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in WI - H2450-023-0
Benefit Details
|
St. Croix |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Value w/Rx 2 (Cost) in WI - H2450-023-0
Benefit Details
|
Sawyer |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Value w/Rx 2 (Cost) in WI - H2450-023-0
Benefit Details
|
Washburn |
$113.20 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Drug: 50% Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
|