Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-1
Benefit Details
|
Allegan |
$38.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-1
Benefit Details
|
Barry |
$38.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-1
Benefit Details
|
Ionia |
$38.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 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 |
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-1
Benefit Details
|
Kalamazoo |
$38.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-1
Benefit Details
|
Mason |
$38.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-1
Benefit Details
|
Muskegon |
$38.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 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 |
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-1
Benefit Details
|
Newaygo |
$38.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-1
Benefit Details
|
Oceana |
$38.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-1
Benefit Details
|
Ottawa |
$38.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 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 |
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-2
Benefit Details
|
Berrien |
$73.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-2
Benefit Details
|
Branch |
$73.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-2
Benefit Details
|
Calhoun |
$73.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 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 |
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-2
Benefit Details
|
Eaton |
$73.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-2
Benefit Details
|
Gratiot |
$73.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-2
Benefit Details
|
Hillsdale |
$73.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 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 |
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-2
Benefit Details
|
Ingham |
$73.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-2
Benefit Details
|
Jackson |
$73.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-2
Benefit Details
|
Monroe |
$73.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 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 |
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-2
Benefit Details
|
Montcalm |
$73.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-2
Benefit Details
|
St. Joseph |
$73.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-2
Benefit Details
|
Van Buren |
$73.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 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 |
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-3
Benefit Details
|
Alcona |
$98.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-3
Benefit Details
|
Alger |
$98.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-3
Benefit Details
|
Alpena |
$98.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 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 |
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-3
Benefit Details
|
Arenac |
$98.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-3
Benefit Details
|
Baraga |
$98.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-3
Benefit Details
|
Bay |
$98.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 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 |
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-3
Benefit Details
|
Charlevoix |
$98.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-3
Benefit Details
|
Cheboygan |
$98.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-3
Benefit Details
|
Chippewa |
$98.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 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 |
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-3
Benefit Details
|
Clare |
$98.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-3
Benefit Details
|
Crawford |
$98.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-3
Benefit Details
|
Gladwin |
$98.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 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 |
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-3
Benefit Details
|
Huron |
$98.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-3
Benefit Details
|
Iosco |
$98.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-3
Benefit Details
|
Kalkaska |
$98.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 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 |
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-3
Benefit Details
|
Keweenaw |
$98.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-3
Benefit Details
|
Luce |
$98.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-3
Benefit Details
|
Mackinac |
$98.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 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 |
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-3
Benefit Details
|
Montmorency |
$98.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-3
Benefit Details
|
Ogemaw |
$98.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-3
Benefit Details
|
Ontonagon |
$98.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 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 |
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-3
Benefit Details
|
Oscoda |
$98.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-3
Benefit Details
|
Presque Isle |
$98.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-3
Benefit Details
|
Roscommon |
$98.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 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 |
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-3
Benefit Details
|
Saginaw |
$98.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-3
Benefit Details
|
Sanilac |
$98.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-3
Benefit Details
|
Schoolcraft |
$98.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 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 |
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-3
Benefit Details
|
Shiawassee |
$98.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-3
Benefit Details
|
Tuscola |
$98.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-4
Benefit Details
|
Antrim |
$78.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 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 |
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-4
Benefit Details
|
Benzie |
$78.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-4
Benefit Details
|
Cass |
$78.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-4
Benefit Details
|
Clinton |
$78.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 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 |
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-4
Benefit Details
|
Delta |
$78.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-4
Benefit Details
|
Dickinson |
$78.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-4
Benefit Details
|
Emmet |
$78.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 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 |
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-4
Benefit Details
|
Genesee |
$78.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-4
Benefit Details
|
Gogebic |
$78.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-4
Benefit Details
|
Grand Traverse |
$78.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 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 |
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-4
Benefit Details
|
Houghton |
$78.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-4
Benefit Details
|
Iron |
$78.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-4
Benefit Details
|
Isabella |
$78.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 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 |
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-4
Benefit Details
|
Kent |
$78.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-4
Benefit Details
|
Lake |
$78.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-4
Benefit Details
|
Lapeer |
$78.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 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 |
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-4
Benefit Details
|
Leelanau |
$78.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-4
Benefit Details
|
Lenawee |
$78.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-4
Benefit Details
|
Livingston |
$78.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 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 |
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-4
Benefit Details
|
Manistee |
$78.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-4
Benefit Details
|
Marquette |
$78.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-4
Benefit Details
|
Mecosta |
$78.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 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 |
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-4
Benefit Details
|
Menominee |
$78.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-4
Benefit Details
|
Midland |
$78.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-4
Benefit Details
|
Missaukee |
$78.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 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 |
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-4
Benefit Details
|
Osceola |
$78.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-4
Benefit Details
|
Otsego |
$78.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-4
Benefit Details
|
St. Clair |
$78.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 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 |
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-4
Benefit Details
|
Wexford |
$78.00 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-6
Benefit Details
|
Macomb |
$78.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-6
Benefit Details
|
Oakland |
$78.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 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 |
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-6
Benefit Details
|
Washtenaw |
$78.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare Plus Blue PPO Vitality (PPO) in MI - H9572-002-6
Benefit Details
|
Wayne |
$78.40 |
$350 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $11.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,000 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|