Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Appling |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Atkinson |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Bacon |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Baker |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Baldwin |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Banks |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Barrow |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Bartow |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Ben Hill |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Berrien |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Bibb |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Bleckley |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Brantley |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Brooks |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Bryan |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Bulloch |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Burke |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Butts |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Calhoun |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Camden |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Candler |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Carroll |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Catoosa |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Charlton |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Chatham |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Chattahoochee |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Chattooga |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Cherokee |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Clarke |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Clay |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Clayton |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Clinch |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Cobb |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Coffee |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Colquitt |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Columbia |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Cook |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Coweta |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Crawford |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Crisp |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Dade |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Dawson |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Decatur |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
DeKalb |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Dodge |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Dooly |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Dougherty |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Douglas |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Early |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Echols |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Effingham |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Elbert |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Emanuel |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Evans |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Fannin |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Fayette |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Floyd |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Forsyth |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Franklin |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Fulton |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Gilmer |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Glascock |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Glynn |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Gordon |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Grady |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Greene |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Gwinnett |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Habersham |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Hall |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Hancock |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Haralson |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Harris |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Hart |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Heard |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Henry |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Houston |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Irwin |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Jackson |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Jasper |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Jeff Davis |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Jefferson |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Jenkins |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Johnson |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Jones |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Lamar |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Lanier |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Laurens |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Lee |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Liberty |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Lincoln |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Long |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Lowndes |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Lumpkin |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
McDuffie |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
McIntosh |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Macon |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Madison |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Marion |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Meriwether |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Miller |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Mitchell |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Monroe |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Montgomery |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Morgan |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Murray |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Muscogee |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Newton |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Oconee |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Oglethorpe |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Paulding |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Peach |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Pickens |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Pierce |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Pike |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Polk |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Pulaski |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Putnam |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Quitman |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Rabun |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Randolph |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Richmond |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Rockdale |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Schley |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Screven |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Seminole |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Spalding |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Stephens |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Stewart |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Sumter |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Talbot |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Taliaferro |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Tattnall |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Taylor |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Telfair |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Terrell |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Thomas |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Tift |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Toombs |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Towns |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Treutlen |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Troup |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Turner |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Twiggs |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Union |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Upson |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Walker |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Walton |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Ware |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Warren |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Washington |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Wayne |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Webster |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Wheeler |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
White |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Whitfield |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Wilcox |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Wilkes |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Wilkinson |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in GA - R7444-010-0
Benefit Details
|
Worth |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Abbeville |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Aiken |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Allendale |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Anderson |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Bamberg |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Barnwell |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Beaufort |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Berkeley |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Calhoun |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Charleston |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Cherokee |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Chester |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Chesterfield |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Clarendon |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Colleton |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Darlington |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Dillon |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Dorchester |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Edgefield |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Fairfield |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Florence |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Georgetown |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Greenville |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Greenwood |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Hampton |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Horry |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Jasper |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Kershaw |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Lancaster |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Laurens |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Lee |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Lexington |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
McCormick |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Marion |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Marlboro |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Newberry |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Oconee |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Orangeburg |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Pickens |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Richland |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Saluda |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Spartanburg |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Sumter |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Union |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
Williamsburg |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Care Improvement Plus Gold Rx (Regional PPO SNP) in SC - R7444-010-0
Benefit Details
|
York |
$19.00 |
$210 Tier 1, 2, and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|