Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-1
Benefit Details
|
Anoka |
$167.50 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-1
Benefit Details
|
Carver |
$167.50 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-1
Benefit Details
|
Chisago |
$167.50 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 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 |
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-1
Benefit Details
|
Dakota |
$167.50 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-1
Benefit Details
|
Hennepin |
$167.50 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-1
Benefit Details
|
Isanti |
$167.50 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 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 |
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-1
Benefit Details
|
Ramsey |
$167.50 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-1
Benefit Details
|
Scott |
$167.50 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-1
Benefit Details
|
Washington |
$167.50 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 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 |
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Becker |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Beltrami |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Benton |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 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 |
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Big Stone |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Cass |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Chippewa |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Clay |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Clearwater |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Cottonwood |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 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 |
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Crow Wing |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Douglas |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Grant |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Hubbard |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Jackson |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Kandiyohi |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Kittson |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Lac qui Parle |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Lake of the Woods |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 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 |
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Lincoln |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Lyon |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Mahnomen |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Marshall |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Morrison |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Murray |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 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 |
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Nobles |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Norman |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Otter Tail |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 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 |
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Pennington |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Polk |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Pope |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Red Lake |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Redwood |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Renville |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Roseau |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Sherburne |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Stearns |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Swift |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Todd |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Wadena |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Wilkin |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Complete (PPO) in MN - H5959-010-2
Benefit Details
|
Wright |
$198.80 |
$415 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: 15% Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $3,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|