Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Adams |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Ashland |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Barron |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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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 |
Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Bayfield |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Brown |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Buffalo |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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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 |
Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Burnett |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Chippewa |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Clark |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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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 |
Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Columbia |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Crawford |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Dane |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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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 |
Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Door |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Douglas |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Dunn |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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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 |
Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Eau Claire |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Florence |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Forest |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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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 |
Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Green |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Green Lake |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Iowa |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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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 |
Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Iron |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Jackson |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Jefferson |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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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 |
Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Juneau |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Kewaunee |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
La Crosse |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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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 |
Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Langlade |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Lincoln |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Marathon |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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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 |
Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Marinette |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Marquette |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Monroe |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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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 |
Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Oconto |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Oneida |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Outagamie |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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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 |
Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Pepin |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Pierce |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Polk |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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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 |
Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Portage |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Price |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Richland |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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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 |
Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Rusk |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Sauk |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Sawyer |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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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 |
Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Shawano |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Taylor |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Trempealeau |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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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 |
Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Vernon |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Vilas |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Washburn |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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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 |
Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Waukesha |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Waupaca |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Waushara |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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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 |
Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Winnebago |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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Esteem Rx (HMO-POS) in WI - H5211-012-0
Benefit Details
|
Wood |
$0.00 |
$250 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28% Vaccines: $0.00
select insulin pay $35 copay | $5,000 Browse Formulary |
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