Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Aitkin |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Anoka |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Becker |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Beltrami |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Benton |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Big Stone |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Blue Earth |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Brown |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Carlton |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Carver |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Cass |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Chippewa |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Chisago |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Clay |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Clearwater |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Cook |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Cottonwood |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Crow Wing |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Dakota |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Dodge |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Douglas |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Faribault |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Fillmore |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Freeborn |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Goodhue |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Grant |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Hennepin |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Houston |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Hubbard |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Isanti |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Itasca |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Jackson |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Kanabec |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Kandiyohi |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Kittson |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Koochiching |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Lac qui Parle |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Lake |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Lake of the Woods |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Le Sueur |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Lincoln |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Lyon |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
McLeod |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Mahnomen |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Marshall |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Martin |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Meeker |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Mille Lacs |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Morrison |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Mower |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Murray |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Nicollet |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Nobles |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Norman |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Olmsted |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Otter Tail |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Pennington |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Pine |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Pipestone |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Polk |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Pope |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Ramsey |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Red Lake |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Redwood |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Renville |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Rice |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Rock |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Roseau |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
St. Louis |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Scott |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Sherburne |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Sibley |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Stearns |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Steele |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Stevens |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Swift |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Todd |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Traverse |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Wabasha |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Wadena |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Waseca |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Washington |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Watonwan |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Wilkin |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Winona |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Wright |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platinum Blue Complete Plan with Rx (Cost) in MN - H2461-010-0
Benefit Details
|
Yellow Medicine |
$197.10 |
$405 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|