PriorityMedicare Ideal (PPO) in MI - H4875-018-1
Benefit Details
|
Allegan |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-1
Benefit Details
|
Barry |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-1
Benefit Details
|
Kent |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 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 |
PriorityMedicare Ideal (PPO) in MI - H4875-018-1
Benefit Details
|
Lenawee |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-1
Benefit Details
|
Newaygo |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-1
Benefit Details
|
Ottawa |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 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 |
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefit Details
|
Berrien |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefit Details
|
Cass |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefit Details
|
Ionia |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 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 |
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefit Details
|
Isabella |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefit Details
|
Kalamazoo |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefit Details
|
Mason |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 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 |
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefit Details
|
Midland |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefit Details
|
Missaukee |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefit Details
|
Montcalm |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 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 |
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefit Details
|
Muskegon |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefit Details
|
Oceana |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefit Details
|
Osceola |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 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 |
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefit Details
|
Otsego |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefit Details
|
St. Clair |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefit Details
|
Van Buren |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 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 |
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefit Details
|
Wexford |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefit Details
|
Alcona |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefit Details
|
Antrim |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 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 |
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefit Details
|
Benzie |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefit Details
|
Charlevoix |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefit Details
|
Clare |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 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 |
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefit Details
|
Clinton |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefit Details
|
Crawford |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefit Details
|
Grand Traverse |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 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 |
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefit Details
|
Hillsdale |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefit Details
|
Ingham |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefit Details
|
Lake |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 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 |
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefit Details
|
Lapeer |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefit Details
|
Leelanau |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefit Details
|
Livingston |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 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 |
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefit Details
|
Manistee |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefit Details
|
Mecosta |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefit Details
|
Monroe |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 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 |
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefit Details
|
Alpena |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefit Details
|
Calhoun |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefit Details
|
Cheboygan |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 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 |
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefit Details
|
Eaton |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefit Details
|
Emmet |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefit Details
|
Gladwin |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 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 |
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefit Details
|
Gratiot |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefit Details
|
Iosco |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefit Details
|
Jackson |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 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 |
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefit Details
|
Kalkaska |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefit Details
|
Montmorency |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefit Details
|
Oscoda |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefit Details
|
Presque Isle |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefit Details
|
Roscommon |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefit Details
|
St. Joseph |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 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 |
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefit Details
|
Sanilac |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefit Details
|
Shiawassee |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-5
Benefit Details
|
Arenac |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 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 |
PriorityMedicare Ideal (PPO) in MI - H4875-018-5
Benefit Details
|
Bay |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-5
Benefit Details
|
Branch |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-5
Benefit Details
|
Genesee |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 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 |
PriorityMedicare Ideal (PPO) in MI - H4875-018-5
Benefit Details
|
Huron |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-5
Benefit Details
|
Macomb |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-5
Benefit Details
|
Oakland |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 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 |
PriorityMedicare Ideal (PPO) in MI - H4875-018-5
Benefit Details
|
Ogemaw |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-5
Benefit Details
|
Saginaw |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-5
Benefit Details
|
Tuscola |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 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 |
PriorityMedicare Ideal (PPO) in MI - H4875-018-5
Benefit Details
|
Washtenaw |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-5
Benefit Details
|
Wayne |
$14.00 |
$125 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 45% Specialty Tier: 30%
| $6,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|