Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-1
Benefit Details
|
Allegan |
$129.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-1
Benefit Details
|
Barry |
$129.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-1
Benefit Details
|
Ionia |
$129.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 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 |
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-1
Benefit Details
|
Kalamazoo |
$129.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-1
Benefit Details
|
Mason |
$129.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-1
Benefit Details
|
Muskegon |
$129.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 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 |
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-1
Benefit Details
|
Newaygo |
$129.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-1
Benefit Details
|
Oceana |
$129.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-1
Benefit Details
|
Ottawa |
$129.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 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 |
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-2
Benefit Details
|
Berrien |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-2
Benefit Details
|
Branch |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-2
Benefit Details
|
Calhoun |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 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 |
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-2
Benefit Details
|
Eaton |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-2
Benefit Details
|
Gratiot |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-2
Benefit Details
|
Hillsdale |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 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 |
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-2
Benefit Details
|
Ingham |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-2
Benefit Details
|
Jackson |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-2
Benefit Details
|
Monroe |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 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 |
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-2
Benefit Details
|
Montcalm |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-2
Benefit Details
|
St. Joseph |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-2
Benefit Details
|
Van Buren |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 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 |
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-3
Benefit Details
|
Alcona |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-3
Benefit Details
|
Alger |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-3
Benefit Details
|
Alpena |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 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 |
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-3
Benefit Details
|
Arenac |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-3
Benefit Details
|
Baraga |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-3
Benefit Details
|
Bay |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 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 |
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-3
Benefit Details
|
Charlevoix |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-3
Benefit Details
|
Cheboygan |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-3
Benefit Details
|
Chippewa |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 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 |
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-3
Benefit Details
|
Clare |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-3
Benefit Details
|
Crawford |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-3
Benefit Details
|
Gladwin |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 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 |
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-3
Benefit Details
|
Huron |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-3
Benefit Details
|
Iosco |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-3
Benefit Details
|
Kalkaska |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 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 |
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-3
Benefit Details
|
Keweenaw |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-3
Benefit Details
|
Luce |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-3
Benefit Details
|
Mackinac |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 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 |
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-3
Benefit Details
|
Montmorency |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-3
Benefit Details
|
Ogemaw |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-3
Benefit Details
|
Ontonagon |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 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 |
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-3
Benefit Details
|
Oscoda |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-3
Benefit Details
|
Presque Isle |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-3
Benefit Details
|
Roscommon |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 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 |
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-3
Benefit Details
|
Saginaw |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-3
Benefit Details
|
Sanilac |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-3
Benefit Details
|
Schoolcraft |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 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 |
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-3
Benefit Details
|
Shiawassee |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-3
Benefit Details
|
Tuscola |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-4
Benefit Details
|
Antrim |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 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 |
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-4
Benefit Details
|
Benzie |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-4
Benefit Details
|
Cass |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-4
Benefit Details
|
Clinton |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 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 |
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-4
Benefit Details
|
Delta |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-4
Benefit Details
|
Dickinson |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-4
Benefit Details
|
Emmet |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 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 |
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-4
Benefit Details
|
Genesee |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-4
Benefit Details
|
Gogebic |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-4
Benefit Details
|
Grand Traverse |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 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 |
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-4
Benefit Details
|
Houghton |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-4
Benefit Details
|
Iron |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-4
Benefit Details
|
Isabella |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 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 |
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-4
Benefit Details
|
Kent |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-4
Benefit Details
|
Lake |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-4
Benefit Details
|
Lapeer |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 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 |
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-4
Benefit Details
|
Leelanau |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-4
Benefit Details
|
Lenawee |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-4
Benefit Details
|
Livingston |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 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 |
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-4
Benefit Details
|
Manistee |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-4
Benefit Details
|
Marquette |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-4
Benefit Details
|
Mecosta |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 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 |
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-4
Benefit Details
|
Menominee |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-4
Benefit Details
|
Midland |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-4
Benefit Details
|
Missaukee |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 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 |
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-4
Benefit Details
|
Osceola |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-4
Benefit Details
|
Otsego |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-4
Benefit Details
|
St. Clair |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 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 |
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-4
Benefit Details
|
Wexford |
$179.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-6
Benefit Details
|
Macomb |
$172.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-6
Benefit Details
|
Oakland |
$172.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 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 |
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-6
Benefit Details
|
Washtenaw |
$172.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Signature (PPO) in MI - H9572-001-6
Benefit Details
|
Wayne |
$172.50 |
$105 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: 48% Specialty Tier: 30%
| $4,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|