Blue Medicare Essential Plus (HMO) in NC - H3449-023-1
Benefit Details
|
Alamance |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,200 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-1
Benefit Details
|
Buncombe |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,200 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-1
Benefit Details
|
Burke |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,200 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Medicare Essential Plus (HMO) in NC - H3449-023-1
Benefit Details
|
Catawba |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,200 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-1
Benefit Details
|
Davidson |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,200 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-1
Benefit Details
|
Durham |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,200 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Medicare Essential Plus (HMO) in NC - H3449-023-1
Benefit Details
|
Forsyth |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,200 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-1
Benefit Details
|
Guilford |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,200 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-1
Benefit Details
|
Haywood |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,200 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Medicare Essential Plus (HMO) in NC - H3449-023-1
Benefit Details
|
Mecklenburg |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,200 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-1
Benefit Details
|
Orange |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,200 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-1
Benefit Details
|
Randolph |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,200 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Medicare Essential Plus (HMO) in NC - H3449-023-1
Benefit Details
|
Rockingham |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,200 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-1
Benefit Details
|
Rutherford |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,200 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-1
Benefit Details
|
Wake |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $4,200 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Medicare Essential Plus (HMO) in NC - H3449-023-2
Benefit Details
|
Alexander |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-2
Benefit Details
|
Brunswick |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-2
Benefit Details
|
Cabarrus |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Medicare Essential Plus (HMO) in NC - H3449-023-2
Benefit Details
|
Cumberland |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,400 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-2
Benefit Details
|
Franklin |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,400 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-2
Benefit Details
|
Henderson |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Medicare Essential Plus (HMO) in NC - H3449-023-2
Benefit Details
|
Hoke |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,400 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-2
Benefit Details
|
Jackson |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,400 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-2
Benefit Details
|
McDowell |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Medicare Essential Plus (HMO) in NC - H3449-023-2
Benefit Details
|
Macon |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,400 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-2
Benefit Details
|
Madison |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,400 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-2
Benefit Details
|
Mitchell |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Medicare Essential Plus (HMO) in NC - H3449-023-2
Benefit Details
|
Moore |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,400 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-2
Benefit Details
|
New Hanover |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,400 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-2
Benefit Details
|
Person |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Medicare Essential Plus (HMO) in NC - H3449-023-2
Benefit Details
|
Polk |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,400 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-2
Benefit Details
|
Rowan |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,400 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-2
Benefit Details
|
Transylvania |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Medicare Essential Plus (HMO) in NC - H3449-023-2
Benefit Details
|
Union |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,400 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-2
Benefit Details
|
Yancey |
$0.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $5,400 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-4
Benefit Details
|
Anson |
$19.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Medicare Essential Plus (HMO) in NC - H3449-023-4
Benefit Details
|
Caswell |
$19.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-4
Benefit Details
|
Chatham |
$19.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-4
Benefit Details
|
Granville |
$19.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Medicare Essential Plus (HMO) in NC - H3449-023-4
Benefit Details
|
Johnston |
$19.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-4
Benefit Details
|
Montgomery |
$19.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-4
Benefit Details
|
Stanly |
$19.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Medicare Essential Plus (HMO) in NC - H3449-023-4
Benefit Details
|
Stokes |
$19.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-4
Benefit Details
|
Surry |
$19.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-4
Benefit Details
|
Vance |
$19.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Medicare Essential Plus (HMO) in NC - H3449-023-4
Benefit Details
|
Warren |
$19.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Alleghany |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Ashe |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Avery |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Beaufort |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Bertie |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Bladen |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Caldwell |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Chowan |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Cleveland |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Columbus |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Davie |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Duplin |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Edgecombe |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Gaston |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Gates |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Greene |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Halifax |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Harnett |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Hertford |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Hyde |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Iredell |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Jones |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Lee |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Lincoln |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Martin |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Nash |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Northampton |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Pamlico |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Pender |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Pitt |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Richmond |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Robeson |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Sampson |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Scotland |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Tyrrell |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Washington |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Watauga |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Wayne |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Wilkes |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Wilson |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Medicare Essential Plus (HMO) in NC - H3449-023-5
Benefit Details
|
Yadkin |
$39.00 |
$195 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|