Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Anoka |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% 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 Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Becker |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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new |
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Higher cost-sharing at standard network pharmacies. Details:
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Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Beltrami |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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new |
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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 Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Benton |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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new |
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Higher cost-sharing at standard network pharmacies. Details:
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Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Big Stone |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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new |
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Higher cost-sharing at standard network pharmacies. Details:
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Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Carver |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
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 Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Cass |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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new |
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Higher cost-sharing at standard network pharmacies. Details:
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Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Chippewa |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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new |
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Higher cost-sharing at standard network pharmacies. Details:
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Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Chisago |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
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 Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Clay |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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new |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Clearwater |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% 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 Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Crow Wing |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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new |
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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 Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Dakota |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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new |
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Higher cost-sharing at standard network pharmacies. Details:
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Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Dodge |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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new |
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Higher cost-sharing at standard network pharmacies. Details:
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Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Douglas |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
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 Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Fillmore |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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new |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Grant |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% 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 Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Hennepin |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
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 Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Houston |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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new |
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Higher cost-sharing at standard network pharmacies. Details:
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Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Hubbard |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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new |
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Higher cost-sharing at standard network pharmacies. Details:
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Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Isanti |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
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 Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Kanabec |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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new |
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Higher cost-sharing at standard network pharmacies. Details:
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Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Kandiyohi |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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new |
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Higher cost-sharing at standard network pharmacies. Details:
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Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Kittson |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
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 Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Lac qui Parle |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
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Higher cost-sharing at standard network pharmacies. Details:
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Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Lincoln |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
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Higher cost-sharing at standard network pharmacies. Details:
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Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Lyon |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
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 Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
McLeod |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
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Higher cost-sharing at standard network pharmacies. Details:
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Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Mahnomen |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
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Higher cost-sharing at standard network pharmacies. Details:
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Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Marshall |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
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 Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Meeker |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
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Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Mille Lacs |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
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Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Morrison |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
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 Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Murray |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
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Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Nobles |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
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Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Norman |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
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 Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Otter Tail |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
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Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Pennington |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
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Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Polk |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
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 Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Pope |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Red Lake |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Renville |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
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 Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Roseau |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Scott |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
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Higher cost-sharing at standard network pharmacies. Details:
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Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Sherburne |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
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 Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Stearns |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Swift |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Todd |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
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 Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Wabasha |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Wadena |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Waseca |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
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 Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Washington |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Wilkin |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Winona |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
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 Cross Medicare Advantage Core (PPO) in MN - H5959-001-0
Benefit Details
|
Wright |
$52.10 |
$405 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $13.00 Preferred Brand: 16% Non-Preferred Brand: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
new |
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|