SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Anderson |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Austin |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Bastrop |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Bell |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Blanco |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Bosque |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Brazos |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Burleson |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Burnet |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Cass |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Cherokee |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Coke |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Coleman |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Colorado |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Concho |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Coryell |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Crockett |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Falls |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Fayette |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Freestone |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Gregg |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Grimes |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Hamilton |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Harrison |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Henderson |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Hill |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Irion |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Kimble |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Lampasas |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Lavaca |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Lee |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Leon |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Limestone |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Llano |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
McCulloch |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
McLennan |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Madison |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Marion |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Mason |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Menard |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Milam |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Mills |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Rains |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Reagan |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Robertson |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Runnels |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Rusk |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
San Saba |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Schleicher |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Smith |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Somervell |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Sterling |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Sutton |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Tom Green |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Travis |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Van Zandt |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Waller |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Washington |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Williamson |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|
SeniorCare Select - Value Rx (Cost) in TX - H4564-015-0
Benefit Details
|
Wood |
$57.60 |
$285 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $6,700 Browse Formulary |
|
|
|
|