Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Aitkin |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Anoka |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Becker |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 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 |
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Beltrami |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Benton |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Big Stone |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 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 |
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Blue Earth |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Brown |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Carlton |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 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 |
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Carver |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Cass |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Chippewa |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 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 |
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Chisago |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Clay |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Clearwater |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 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 |
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Cook |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Cottonwood |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Crow Wing |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 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 |
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Dakota |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Dodge |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Douglas |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 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 |
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Faribault |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Fillmore |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Freeborn |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 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 |
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Goodhue |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Grant |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Hennepin |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 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 |
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Houston |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Hubbard |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Isanti |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 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 |
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Itasca |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Jackson |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Kanabec |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 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 |
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Kandiyohi |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Kittson |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Koochiching |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 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 |
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Lac qui Parle |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Lake |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Lake of the Woods |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 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 |
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Le Sueur |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Lincoln |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Lyon |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 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 |
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
McLeod |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Mahnomen |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Marshall |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 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 |
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Martin |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Meeker |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Mille Lacs |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 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 |
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Morrison |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Mower |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Murray |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 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 |
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Nicollet |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Nobles |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Norman |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 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 |
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Olmsted |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Otter Tail |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
|
|
|
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Pennington |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 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 Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Pine |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
|
|
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Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Pipestone |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
|
|
|
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Polk |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 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 Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Pope |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
|
|
|
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Ramsey |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
|
|
|
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Red Lake |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 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 Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Redwood |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
|
|
|
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Renville |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
|
|
|
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Rice |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 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 Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Rock |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
|
|
|
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Roseau |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
|
|
|
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
St. Louis |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 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 Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Scott |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
|
|
|
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Sherburne |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
|
|
|
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Sibley |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 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 Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Stearns |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
|
|
|
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Steele |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
|
|
|
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Stevens |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 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 Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Swift |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
|
|
|
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Todd |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
|
|
|
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Traverse |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 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 Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Wabasha |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
|
|
|
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Wadena |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
|
|
|
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Waseca |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 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 Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Washington |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
|
|
|
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Watonwan |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
|
|
|
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Wilkin |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 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 Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Winona |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
|
|
|
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Wright |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
|
|
|
Medica Prime Solution Basic w/Rx (Cost) in MN - H2450-016-0
Benefit Details
|
Yellow Medicine |
$108.30 |
$260 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $27.00 Non-Preferred Drug: 50% Specialty Tier: 27%
| $3,400 Browse Formulary |
|
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|
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