Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-1
Benefit Details
|
Alamance |
$98.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-1
Benefit Details
|
Anson |
$98.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-1
Benefit Details
|
Buncombe |
$98.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 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 |
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-1
Benefit Details
|
Cabarrus |
$98.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-1
Benefit Details
|
Catawba |
$98.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-1
Benefit Details
|
Cumberland |
$98.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 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 |
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-1
Benefit Details
|
Davidson |
$98.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-1
Benefit Details
|
Forsyth |
$98.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-1
Benefit Details
|
Guilford |
$98.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 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 |
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-1
Benefit Details
|
Harnett |
$98.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-1
Benefit Details
|
Haywood |
$98.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-1
Benefit Details
|
Henderson |
$98.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 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 |
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-1
Benefit Details
|
Hoke |
$98.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-1
Benefit Details
|
McDowell |
$98.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-1
Benefit Details
|
Madison |
$98.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 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 |
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-1
Benefit Details
|
Mecklenburg |
$98.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-1
Benefit Details
|
Mitchell |
$98.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-1
Benefit Details
|
Orange |
$98.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 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 |
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-1
Benefit Details
|
Polk |
$98.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-1
Benefit Details
|
Randolph |
$98.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-1
Benefit Details
|
Richmond |
$98.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 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 |
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-1
Benefit Details
|
Rockingham |
$98.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-1
Benefit Details
|
Rowan |
$98.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-1
Benefit Details
|
Scotland |
$98.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 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 |
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-1
Benefit Details
|
Stokes |
$98.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-1
Benefit Details
|
Surry |
$98.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-1
Benefit Details
|
Transylvania |
$98.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 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 |
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-1
Benefit Details
|
Yancey |
$98.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Alexander |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Beaufort |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 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 |
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Bertie |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Bladen |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Brunswick |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 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 |
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Caldwell |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Caswell |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Chatham |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 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 |
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Chowan |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Cleveland |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Columbus |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 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 |
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Duplin |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Edgecombe |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Gaston |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 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 |
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Gates |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Hertford |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Iredell |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 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 |
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Jones |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Lee |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Martin |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 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 |
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Nash |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Person |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
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Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Pitt |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 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 |
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Robeson |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Sampson |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Wake |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 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 |
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Warren |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Washington |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Watauga |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 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 |
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Wayne |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Wilkes |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare PPO Enhanced (PPO) in NC - H3404-003-2
Benefit Details
|
Wilson |
$113.60 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $6.00 Preferred Brand: $37.00 Non-Preferred Brand: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|