Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
Adams |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
Barnes |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
Benson |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in ND - H2450-034-0
Benefit Details
|
Billings |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
Bowman |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
Burleigh |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in ND - H2450-034-0
Benefit Details
|
Cass |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
Cavalier |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
Dickey |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in ND - H2450-034-0
Benefit Details
|
Dunn |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
Eddy |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
Emmons |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in ND - H2450-034-0
Benefit Details
|
Foster |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
Grand Forks |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
Grant |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in ND - H2450-034-0
Benefit Details
|
Griggs |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
Hettinger |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
Kidder |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in ND - H2450-034-0
Benefit Details
|
LaMoure |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
Logan |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
McHenry |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in ND - H2450-034-0
Benefit Details
|
McIntosh |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
McLean |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
Mercer |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in ND - H2450-034-0
Benefit Details
|
Morton |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
Nelson |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
Oliver |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in ND - H2450-034-0
Benefit Details
|
Pembina |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
Pierce |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
Ramsey |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in ND - H2450-034-0
Benefit Details
|
Ransom |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
Richland |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
Rolette |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in ND - H2450-034-0
Benefit Details
|
Sargent |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
Sheridan |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
Sioux |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in ND - H2450-034-0
Benefit Details
|
Slope |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
Stark |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
Steele |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in ND - H2450-034-0
Benefit Details
|
Stutsman |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
Towner |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
Traill |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in ND - H2450-034-0
Benefit Details
|
Walsh |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
Ward |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in ND - H2450-034-0
Benefit Details
|
Wells |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in ND - H2450-034-0
Benefit Details
|
Williams |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Aurora |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Beadle |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in SD - H2450-034-0
Benefit Details
|
Bennett |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Bon Homme |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Brookings |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in SD - H2450-034-0
Benefit Details
|
Brown |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Brule |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Buffalo |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in SD - H2450-034-0
Benefit Details
|
Butte |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Campbell |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Charles Mix |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in SD - H2450-034-0
Benefit Details
|
Clark |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Clay |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Codington |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in SD - H2450-034-0
Benefit Details
|
Corson |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Custer |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Davison |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in SD - H2450-034-0
Benefit Details
|
Day |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Deuel |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Dewey |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in SD - H2450-034-0
Benefit Details
|
Douglas |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Edmunds |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Fall River |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in SD - H2450-034-0
Benefit Details
|
Faulk |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Grant |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Gregory |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in SD - H2450-034-0
Benefit Details
|
Haakon |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Hamlin |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Hand |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in SD - H2450-034-0
Benefit Details
|
Hanson |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Harding |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Hughes |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in SD - H2450-034-0
Benefit Details
|
Hutchinson |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Hyde |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Jackson |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in SD - H2450-034-0
Benefit Details
|
Jerauld |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Jones |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
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Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Kingsbury |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
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|
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 (Cost) in SD - H2450-034-0
Benefit Details
|
Lake |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
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|
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Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Lawrence |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
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Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Lincoln |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in SD - H2450-034-0
Benefit Details
|
Lyman |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
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Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
McCook |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
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Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
McPherson |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in SD - H2450-034-0
Benefit Details
|
Marshall |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Meade |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Mellette |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in SD - H2450-034-0
Benefit Details
|
Miner |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Minnehaha |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
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Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Moody |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in SD - H2450-034-0
Benefit Details
|
Oglala Lakota |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Pennington |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Perkins |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in SD - H2450-034-0
Benefit Details
|
Potter |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Roberts |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Sanborn |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in SD - H2450-034-0
Benefit Details
|
Spink |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Stanley |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Sully |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in SD - H2450-034-0
Benefit Details
|
Todd |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Tripp |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
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Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Turner |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in SD - H2450-034-0
Benefit Details
|
Union |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Walworth |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in SD - H2450-034-0
Benefit Details
|
Yankton |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
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 (Cost) in SD - H2450-034-0
Benefit Details
|
Ziebach |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in WY - H2450-034-0
Benefit Details
|
Crook |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
|
|
|
Medica Prime Solution Core (Cost) in WY - H2450-034-0
Benefit Details
|
Weston |
$79.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 |
-- |
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