PriorityMedicare Select (PPO) in MI - H4875-017-1
Benefit Details
|
Allegan |
$159.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-1
Benefit Details
|
Barry |
$159.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-1
Benefit Details
|
Kent |
$159.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 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 |
PriorityMedicare Select (PPO) in MI - H4875-017-1
Benefit Details
|
Lenawee |
$159.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-1
Benefit Details
|
Ottawa |
$159.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-2
Benefit Details
|
Berrien |
$149.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Select (PPO) in MI - H4875-017-2
Benefit Details
|
Calhoun |
$149.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-2
Benefit Details
|
Cass |
$149.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-2
Benefit Details
|
Ionia |
$149.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Select (PPO) in MI - H4875-017-2
Benefit Details
|
Isabella |
$149.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-2
Benefit Details
|
Kalamazoo |
$149.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-2
Benefit Details
|
Mason |
$149.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Select (PPO) in MI - H4875-017-2
Benefit Details
|
Midland |
$149.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-2
Benefit Details
|
Missaukee |
$149.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-2
Benefit Details
|
Montcalm |
$149.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Select (PPO) in MI - H4875-017-2
Benefit Details
|
Muskegon |
$149.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-2
Benefit Details
|
Newaygo |
$149.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-2
Benefit Details
|
Oceana |
$149.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Select (PPO) in MI - H4875-017-2
Benefit Details
|
Osceola |
$149.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-2
Benefit Details
|
Otsego |
$149.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-2
Benefit Details
|
St. Clair |
$149.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Select (PPO) in MI - H4875-017-2
Benefit Details
|
Van Buren |
$149.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-2
Benefit Details
|
Wexford |
$149.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-3
Benefit Details
|
Alcona |
$208.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Select (PPO) in MI - H4875-017-3
Benefit Details
|
Antrim |
$208.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-3
Benefit Details
|
Benzie |
$208.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-3
Benefit Details
|
Charlevoix |
$208.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Select (PPO) in MI - H4875-017-3
Benefit Details
|
Clare |
$208.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-3
Benefit Details
|
Crawford |
$208.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-3
Benefit Details
|
Grand Traverse |
$208.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Select (PPO) in MI - H4875-017-3
Benefit Details
|
Hillsdale |
$208.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-3
Benefit Details
|
Lake |
$208.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-3
Benefit Details
|
Lapeer |
$208.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Select (PPO) in MI - H4875-017-3
Benefit Details
|
Leelanau |
$208.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-3
Benefit Details
|
Manistee |
$208.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-3
Benefit Details
|
Mecosta |
$208.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Select (PPO) in MI - H4875-017-3
Benefit Details
|
Monroe |
$208.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-4
Benefit Details
|
Alpena |
$225.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-4
Benefit Details
|
Cheboygan |
$225.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Select (PPO) in MI - H4875-017-4
Benefit Details
|
Eaton |
$225.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-4
Benefit Details
|
Emmet |
$225.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-4
Benefit Details
|
Gladwin |
$225.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Select (PPO) in MI - H4875-017-4
Benefit Details
|
Gratiot |
$225.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-4
Benefit Details
|
Iosco |
$225.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-4
Benefit Details
|
Jackson |
$225.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Select (PPO) in MI - H4875-017-4
Benefit Details
|
Kalkaska |
$225.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-4
Benefit Details
|
Montmorency |
$225.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-4
Benefit Details
|
Oscoda |
$225.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Select (PPO) in MI - H4875-017-4
Benefit Details
|
Presque Isle |
$225.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-4
Benefit Details
|
Roscommon |
$225.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-4
Benefit Details
|
St. Joseph |
$225.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Select (PPO) in MI - H4875-017-4
Benefit Details
|
Sanilac |
$225.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-4
Benefit Details
|
Shiawassee |
$225.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-5
Benefit Details
|
Arenac |
$214.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Select (PPO) in MI - H4875-017-5
Benefit Details
|
Bay |
$214.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-5
Benefit Details
|
Branch |
$214.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-5
Benefit Details
|
Clinton |
$214.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Select (PPO) in MI - H4875-017-5
Benefit Details
|
Genesee |
$214.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-5
Benefit Details
|
Huron |
$214.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-5
Benefit Details
|
Ingham |
$214.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Select (PPO) in MI - H4875-017-5
Benefit Details
|
Livingston |
$214.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-5
Benefit Details
|
Macomb |
$214.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-5
Benefit Details
|
Oakland |
$214.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Select (PPO) in MI - H4875-017-5
Benefit Details
|
Ogemaw |
$214.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-5
Benefit Details
|
Saginaw |
$214.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-5
Benefit Details
|
Tuscola |
$214.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Select (PPO) in MI - H4875-017-5
Benefit Details
|
Washtenaw |
$214.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Select (PPO) in MI - H4875-017-5
Benefit Details
|
Wayne |
$214.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 45% Specialty Tier: 33%
| $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|