UnitedHealthcare MedicareDirect Rx (PFFS) in KS - H5435-024-0
Benefit Details
|
Chase |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in KS - H5435-024-0
Benefit Details
|
Cheyenne |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in KS - H5435-024-0
Benefit Details
|
Clay |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare MedicareDirect Rx (PFFS) in KS - H5435-024-0
Benefit Details
|
Cloud |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in KS - H5435-024-0
Benefit Details
|
Decatur |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in KS - H5435-024-0
Benefit Details
|
Ellis |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare MedicareDirect Rx (PFFS) in KS - H5435-024-0
Benefit Details
|
Geary |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in KS - H5435-024-0
Benefit Details
|
Graham |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in KS - H5435-024-0
Benefit Details
|
Lane |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare MedicareDirect Rx (PFFS) in KS - H5435-024-0
Benefit Details
|
Logan |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in KS - H5435-024-0
Benefit Details
|
Marshall |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in KS - H5435-024-0
Benefit Details
|
Nemaha |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare MedicareDirect Rx (PFFS) in KS - H5435-024-0
Benefit Details
|
Phillips |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in KS - H5435-024-0
Benefit Details
|
Rawlins |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in KS - H5435-024-0
Benefit Details
|
Republic |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare MedicareDirect Rx (PFFS) in KS - H5435-024-0
Benefit Details
|
Riley |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in KS - H5435-024-0
Benefit Details
|
Rooks |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in KS - H5435-024-0
Benefit Details
|
Saline |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare MedicareDirect Rx (PFFS) in KS - H5435-024-0
Benefit Details
|
Scott |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in KS - H5435-024-0
Benefit Details
|
Sheridan |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in KS - H5435-024-0
Benefit Details
|
Thomas |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare MedicareDirect Rx (PFFS) in KS - H5435-024-0
Benefit Details
|
Washington |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in KY - H5435-024-0
Benefit Details
|
Christian |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in MO - H5435-024-0
Benefit Details
|
Adair |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare MedicareDirect Rx (PFFS) in MO - H5435-024-0
Benefit Details
|
Clark |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in MO - H5435-024-0
Benefit Details
|
Daviess |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in MO - H5435-024-0
Benefit Details
|
Grundy |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare MedicareDirect Rx (PFFS) in MO - H5435-024-0
Benefit Details
|
Mercer |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in MO - H5435-024-0
Benefit Details
|
New Madrid |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in MO - H5435-024-0
Benefit Details
|
Putnam |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare MedicareDirect Rx (PFFS) in MO - H5435-024-0
Benefit Details
|
Schuyler |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in MO - H5435-024-0
Benefit Details
|
Scotland |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in MO - H5435-024-0
Benefit Details
|
Sullivan |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-024-0
Benefit Details
|
Carter |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-024-0
Benefit Details
|
Daniels |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-024-0
Benefit Details
|
Dawson |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-024-0
Benefit Details
|
Fallon |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-024-0
Benefit Details
|
Garfield |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-024-0
Benefit Details
|
Petroleum |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-024-0
Benefit Details
|
Phillips |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-024-0
Benefit Details
|
Powder River |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-024-0
Benefit Details
|
Prairie |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-024-0
Benefit Details
|
Roosevelt |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-024-0
Benefit Details
|
Sheridan |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in MT - H5435-024-0
Benefit Details
|
Valley |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare MedicareDirect Rx (PFFS) in NE - H5435-024-0
Benefit Details
|
Arthur |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in NE - H5435-024-0
Benefit Details
|
Banner |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in NE - H5435-024-0
Benefit Details
|
Blaine |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare MedicareDirect Rx (PFFS) in NE - H5435-024-0
Benefit Details
|
Box Butte |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in NE - H5435-024-0
Benefit Details
|
Buffalo |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in NE - H5435-024-0
Benefit Details
|
Cheyenne |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare MedicareDirect Rx (PFFS) in NE - H5435-024-0
Benefit Details
|
Dawson |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in NE - H5435-024-0
Benefit Details
|
Gosper |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in NE - H5435-024-0
Benefit Details
|
Hall |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare MedicareDirect Rx (PFFS) in NE - H5435-024-0
Benefit Details
|
Hamilton |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in NE - H5435-024-0
Benefit Details
|
Hooker |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in NE - H5435-024-0
Benefit Details
|
Kearney |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare MedicareDirect Rx (PFFS) in NE - H5435-024-0
Benefit Details
|
Keith |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in NE - H5435-024-0
Benefit Details
|
Keya Paha |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in NE - H5435-024-0
Benefit Details
|
Logan |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare MedicareDirect Rx (PFFS) in NE - H5435-024-0
Benefit Details
|
Loup |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in NE - H5435-024-0
Benefit Details
|
McPherson |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in NE - H5435-024-0
Benefit Details
|
Merrick |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare MedicareDirect Rx (PFFS) in NE - H5435-024-0
Benefit Details
|
Morrill |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in NE - H5435-024-0
Benefit Details
|
Nance |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in NE - H5435-024-0
Benefit Details
|
Perkins |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare MedicareDirect Rx (PFFS) in NE - H5435-024-0
Benefit Details
|
Scotts Bluff |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in NE - H5435-024-0
Benefit Details
|
Sheridan |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in NE - H5435-024-0
Benefit Details
|
Sherman |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare MedicareDirect Rx (PFFS) in NE - H5435-024-0
Benefit Details
|
Stanton |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in NE - H5435-024-0
Benefit Details
|
Thomas |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in NE - H5435-024-0
Benefit Details
|
Wheeler |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare MedicareDirect Rx (PFFS) in OK - H5435-024-0
Benefit Details
|
Latimer |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in WY - H5435-024-0
Benefit Details
|
Albany |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in WY - H5435-024-0
Benefit Details
|
Crook |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare MedicareDirect Rx (PFFS) in WY - H5435-024-0
Benefit Details
|
Fremont |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in WY - H5435-024-0
Benefit Details
|
Natrona |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in WY - H5435-024-0
Benefit Details
|
Sheridan |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare MedicareDirect Rx (PFFS) in WY - H5435-024-0
Benefit Details
|
Teton |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare MedicareDirect Rx (PFFS) in WY - H5435-024-0
Benefit Details
|
Weston |
$64.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| n/a Browse Formulary |
|
|
|
|