Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Adams |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Barnes |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Benson |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Billings |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Bowman |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Burleigh |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Cass |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Cavalier |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Dickey |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Dunn |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Eddy |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Emmons |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Foster |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Grand Forks |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Grant |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Griggs |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Hettinger |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Kidder |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
LaMoure |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Logan |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
McHenry |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
McIntosh |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
McLean |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Mercer |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Morton |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Nelson |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Oliver |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Pembina |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Pierce |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Ramsey |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Ransom |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Richland |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Rolette |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Sargent |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Sheridan |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Sioux |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Slope |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Stark |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Steele |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Stutsman |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Towner |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Traill |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Walsh |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Ward |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Wells |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in ND - H2450-035-0
Benefit Details
|
Williams |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Aurora |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Beadle |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Bennett |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Bon Homme |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Brookings |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Brown |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Brule |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Buffalo |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Butte |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Campbell |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Charles Mix |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Clark |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Clay |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Codington |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Corson |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Custer |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Davison |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Day |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Deuel |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Dewey |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Douglas |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Edmunds |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Fall River |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Faulk |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Grant |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Gregory |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Haakon |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Hamlin |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Hand |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Hanson |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Harding |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Hughes |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Hutchinson |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Hyde |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Jackson |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Jerauld |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Jones |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Kingsbury |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Lake |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Lawrence |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Lincoln |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Lyman |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
McCook |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
McPherson |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Marshall |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Meade |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Mellette |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Miner |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Minnehaha |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Moody |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Oglala Lakota |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Pennington |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Perkins |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Potter |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Roberts |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Sanborn |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Spink |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Stanley |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Sully |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Todd |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Tripp |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Turner |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Union |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Walworth |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Yankton |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 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 |
Medica Prime Solution Core w/Rx (Cost) in SD - H2450-035-0
Benefit Details
|
Ziebach |
$125.50 |
$365 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $8.00 Preferred Brand: $30.00 Non-Preferred Drug: 50% Specialty Tier: 26%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|