UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Anderson |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Andrews |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Angelina |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a 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 |
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Aransas |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Archer |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Armstrong |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a 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 |
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Atascosa |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Austin |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Bailey |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a 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 |
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Bandera |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Bastrop |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Baylor |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a 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 |
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Bee |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Bell |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Bexar |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a 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 |
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Blanco |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Borden |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Bosque |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a 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 |
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Bowie |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Brazoria |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Brazos |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a 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 |
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Brewster |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Briscoe |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Brooks |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a 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 |
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Brown |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Burleson |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Burnet |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a 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 |
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Caldwell |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Calhoun |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Callahan |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a 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 |
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Cameron |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Camp |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Carson |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a 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 |
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Cass |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Castro |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Chambers |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a 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 |
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Cherokee |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Childress |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Clay |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a 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 |
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Cochran |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Coke |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Coleman |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a 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 |
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Collin |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Collingsworth |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Colorado |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Comal |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Comanche |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Concho |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Cooke |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
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|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Coryell |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Cottle |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Crane |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
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|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Crockett |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Crosby |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Culberson |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Dallam |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Dallas |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Dawson |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Deaf Smith |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Delta |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Denton |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
DeWitt |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Dickens |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Dimmit |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Donley |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Duval |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Eastland |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Ector |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Edwards |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Ellis |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
El Paso |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Erath |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Falls |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Fannin |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Fayette |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Fisher |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Floyd |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Foard |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Fort Bend |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Franklin |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Freestone |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Frio |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Gaines |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Galveston |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Garza |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Gillespie |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Glasscock |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Goliad |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Gonzales |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Gray |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Grayson |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Gregg |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Grimes |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Guadalupe |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Hale |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Hall |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Hamilton |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Hansford |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Hardeman |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Hardin |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Harris |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Harrison |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Hartley |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Haskell |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Hays |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Hemphill |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Henderson |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Hidalgo |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Hill |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Hockley |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Hood |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Hopkins |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Houston |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Howard |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Hudspeth |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Hunt |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Hutchinson |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Irion |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Jack |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Jackson |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Jasper |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Jeff Davis |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Jefferson |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Jim Hogg |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Jim Wells |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Johnson |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Jones |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Karnes |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Kaufman |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Kendall |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Kenedy |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Kent |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Kerr |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Kimble |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
King |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Kinney |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Kleberg |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Knox |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Lamar |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Lamb |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Lampasas |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
La Salle |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Lavaca |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Lee |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Leon |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Liberty |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Limestone |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Lipscomb |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Live Oak |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Llano |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Loving |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Lubbock |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Lynn |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
McCulloch |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
McLennan |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
McMullen |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Madison |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Marion |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Martin |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Mason |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Matagorda |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Maverick |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Medina |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Menard |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Midland |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Milam |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Mills |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Mitchell |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Montague |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Montgomery |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Moore |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Morris |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Motley |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Nacogdoches |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Navarro |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Newton |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Nolan |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Nueces |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Ochiltree |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Oldham |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Orange |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Palo Pinto |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Panola |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Parker |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Parmer |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Pecos |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Polk |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Potter |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Presidio |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Rains |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Randall |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Reagan |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Real |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Red River |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Reeves |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Refugio |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Roberts |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Robertson |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Rockwall |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Runnels |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Rusk |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Sabine |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
San Augustine |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
San Jacinto |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
San Patricio |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
San Saba |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Schleicher |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Scurry |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Shackelford |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Shelby |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a 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 |
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Sherman |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Smith |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Somervell |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Starr |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Stephens |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Sterling |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Stonewall |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Sutton |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Swisher |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Tarrant |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Taylor |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Terrell |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Terry |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
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UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Throckmorton |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
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|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Titus |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Tom Green |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
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|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Travis |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
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|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Trinity |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Tyler |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Upshur |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Upton |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Uvalde |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Val Verde |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Van Zandt |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Victoria |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Walker |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Waller |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Ward |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Washington |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Webb |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Wharton |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Wheeler |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Wichita |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Wilbarger |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Willacy |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Williamson |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Wilson |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Winkler |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Wise |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Wood |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Yoakum |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Young |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | 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 Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Zapata |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Gold (Regional PPO C-SNP) in TX - R6801-009-0
Benefit Details
|
Zavala |
$29.00 |
$295 Tier 1, 2 and 3 exempt |
Some Generics | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | n/a Browse Formulary |
|
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|
|