Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Adams |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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|
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Barnes |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Benson |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Billings |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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|
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Bowman |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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|
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Burleigh |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Cass |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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|
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Cavalier |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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|
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Dickey |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Dunn |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Eddy |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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|
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Emmons |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Foster |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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|
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Grand Forks |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Grant |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Griggs |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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|
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Hettinger |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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|
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Kidder |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
LaMoure |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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|
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Logan |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
McHenry |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
McIntosh |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
McLean |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Mercer |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Morton |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Nelson |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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|
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Oliver |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Pembina |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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|
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Pierce |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Ramsey |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Ransom |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Richland |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Rolette |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Sargent |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Sheridan |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Sioux |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Slope |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Stark |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Steele |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Stutsman |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Towner |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Traill |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Walsh |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Ward |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Wells |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in ND - H2450-037-0
Benefit Details
|
Williams |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Aurora |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Beadle |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Bennett |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Bon Homme |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Brookings |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Brown |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Brule |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Buffalo |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Butte |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Campbell |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Charles Mix |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Clark |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Clay |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Codington |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Corson |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Custer |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Davison |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Day |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Deuel |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Dewey |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Douglas |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Edmunds |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Fall River |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Faulk |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Grant |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Gregory |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Haakon |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Hamlin |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Hand |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Hanson |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Harding |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Hughes |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Hutchinson |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Jackson |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Jerauld |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Jones |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Kingsbury |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Lake |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Lawrence |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Lincoln |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Lyman |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
McCook |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
McPherson |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Marshall |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Meade |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Mellette |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Miner |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Minnehaha |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Moody |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Pennington |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Perkins |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Potter |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Roberts |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Sanborn |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Oglala Lakota |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Spink |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Stanley |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Sully |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Todd |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Tripp |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Turner |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Union |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Walworth |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Yankton |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefit Details
|
Ziebach |
$234.00 |
$215 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $28.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
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