Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Adams |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Allen |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Ashland |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 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 |
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Ashtabula |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Athens |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Auglaize |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 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 |
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Belmont |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Brown |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Butler |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 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 |
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Carroll |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Champaign |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Clark |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 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 |
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Clermont |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Clinton |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Columbiana |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 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 |
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Coshocton |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Crawford |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Cuyahoga |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 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 |
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Darke |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Defiance |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Delaware |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 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 |
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Erie |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Fairfield |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Fayette |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 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 |
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Franklin |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Fulton |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Gallia |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 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 |
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Geauga |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Greene |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Guernsey |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 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 |
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Hamilton |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Hancock |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Hardin |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 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 |
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Harrison |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Henry |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Highland |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 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 |
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Hocking |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Holmes |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Huron |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 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 |
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Jackson |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Jefferson |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Knox |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 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 |
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Lake |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Lawrence |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Licking |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 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 |
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Logan |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Lorain |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Lucas |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 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 |
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Madison |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Mahoning |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Marion |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 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 |
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Medina |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Meigs |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Mercer |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 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 |
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Miami |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Monroe |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Montgomery |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 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 |
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Morgan |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Morrow |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Muskingum |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 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 |
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Noble |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Ottawa |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Paulding |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 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 |
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Perry |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Pickaway |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Pike |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 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 |
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Portage |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Preble |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Putnam |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 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 |
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Richland |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Ross |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Sandusky |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 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 |
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Scioto |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Seneca |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Shelby |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 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 |
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Stark |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Summit |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Trumbull |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 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 |
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Tuscarawas |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Union |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Van Wert |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 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 |
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Vinton |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Warren |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Washington |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 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 |
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Wayne |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Williams |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Wood |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 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 |
Aetna Medicare OH Connect Gold (Regional PPO) in OH - R6694-003-0
Benefit Details
|
Wyandot |
$204.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|