Medica Prime Solution Thrift w/Rx (Cost) in MN - H2450-007-0
Benefit Details
|
Aitkin |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in MN - H2450-007-0
Benefit Details
|
Carlton |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in MN - H2450-007-0
Benefit Details
|
Cook |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in MN - H2450-007-0
Benefit Details
|
Goodhue |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in MN - H2450-007-0
Benefit Details
|
Itasca |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in MN - H2450-007-0
Benefit Details
|
Kanabec |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in MN - H2450-007-0
Benefit Details
|
Koochiching |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in MN - H2450-007-0
Benefit Details
|
Lake |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in MN - H2450-007-0
Benefit Details
|
Le Sueur |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in MN - H2450-007-0
Benefit Details
|
McLeod |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in MN - H2450-007-0
Benefit Details
|
Meeker |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in MN - H2450-007-0
Benefit Details
|
Mille Lacs |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in MN - H2450-007-0
Benefit Details
|
Pine |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in MN - H2450-007-0
Benefit Details
|
Pipestone |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in MN - H2450-007-0
Benefit Details
|
Rice |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in MN - H2450-007-0
Benefit Details
|
Rock |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in MN - H2450-007-0
Benefit Details
|
St. Louis |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in MN - H2450-007-0
Benefit Details
|
Sibley |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in MN - H2450-007-0
Benefit Details
|
Stevens |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in MN - H2450-007-0
Benefit Details
|
Traverse |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in MN - H2450-007-0
Benefit Details
|
Yellow Medicine |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Adams |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Barnes |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Benson |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Billings |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Bowman |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Burleigh |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Cass |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Cavalier |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Dickey |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Dunn |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Eddy |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Emmons |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Foster |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Grand Forks |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Grant |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Griggs |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Hettinger |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Kidder |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
LaMoure |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Logan |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
McHenry |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
McIntosh |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
McLean |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Mercer |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Morton |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Nelson |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Oliver |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Pembina |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Pierce |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Ramsey |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Ransom |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Richland |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Rolette |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Sargent |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Sheridan |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Sioux |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Slope |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Stark |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Steele |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Stutsman |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Towner |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Traill |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Walsh |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Ward |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Wells |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in ND - H2450-007-0
Benefit Details
|
Williams |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Aurora |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Beadle |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Bennett |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Bon Homme |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Brookings |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Brown |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Brule |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Buffalo |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Butte |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Campbell |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Charles Mix |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Clark |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Clay |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Codington |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Corson |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Custer |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Davison |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Day |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Deuel |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Dewey |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Douglas |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Edmunds |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Fall River |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Faulk |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Grant |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Gregory |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Haakon |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Hamlin |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Hand |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Hanson |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Harding |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Hughes |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Hutchinson |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Hyde |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Jackson |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Jerauld |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Jones |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Kingsbury |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Lake |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Lawrence |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Lincoln |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Lyman |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
McCook |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
McPherson |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Marshall |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Meade |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Mellette |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Miner |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Minnehaha |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Moody |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Oglala Lakota |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Pennington |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Perkins |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Potter |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Roberts |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Sanborn |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Spink |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Stanley |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Sully |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Todd |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Tripp |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Turner |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Union |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Walworth |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Yankton |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in SD - H2450-007-0
Benefit Details
|
Ziebach |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in WI - H2450-007-0
Benefit Details
|
Ashland |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in WI - H2450-007-0
Benefit Details
|
Barron |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in WI - H2450-007-0
Benefit Details
|
Bayfield |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in WI - H2450-007-0
Benefit Details
|
Burnett |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in WI - H2450-007-0
Benefit Details
|
Chippewa |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in WI - H2450-007-0
Benefit Details
|
Douglas |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in WI - H2450-007-0
Benefit Details
|
Dunn |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in WI - H2450-007-0
Benefit Details
|
Eau Claire |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in WI - H2450-007-0
Benefit Details
|
Pierce |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in WI - H2450-007-0
Benefit Details
|
Polk |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in WI - H2450-007-0
Benefit Details
|
St. Croix |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
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-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Thrift w/Rx (Cost) in WI - H2450-007-0
Benefit Details
|
Sawyer |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
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-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Thrift w/Rx (Cost) in WI - H2450-007-0
Benefit Details
|
Washburn |
$90.30 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|