Medica Prime Solution Standard w/Rx (Cost) in MN - H2450-049-0
Benefit Details
|
Aitkin |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
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-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in MN - H2450-049-0
Benefit Details
|
Carlton |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
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-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in MN - H2450-049-0
Benefit Details
|
Cook |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 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 Standard w/Rx (Cost) in MN - H2450-049-0
Benefit Details
|
Goodhue |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
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-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in MN - H2450-049-0
Benefit Details
|
Itasca |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
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-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in MN - H2450-049-0
Benefit Details
|
Kanabec |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 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 Standard w/Rx (Cost) in MN - H2450-049-0
Benefit Details
|
Koochiching |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in MN - H2450-049-0
Benefit Details
|
Lake |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in MN - H2450-049-0
Benefit Details
|
Le Sueur |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 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 Standard w/Rx (Cost) in MN - H2450-049-0
Benefit Details
|
McLeod |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in MN - H2450-049-0
Benefit Details
|
Meeker |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in MN - H2450-049-0
Benefit Details
|
Mille Lacs |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 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 Standard w/Rx (Cost) in MN - H2450-049-0
Benefit Details
|
Pine |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in MN - H2450-049-0
Benefit Details
|
Pipestone |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in MN - H2450-049-0
Benefit Details
|
Rice |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 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 Standard w/Rx (Cost) in MN - H2450-049-0
Benefit Details
|
Rock |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in MN - H2450-049-0
Benefit Details
|
St. Louis |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in MN - H2450-049-0
Benefit Details
|
Sibley |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 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 Standard w/Rx (Cost) in MN - H2450-049-0
Benefit Details
|
Stevens |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in MN - H2450-049-0
Benefit Details
|
Traverse |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in MN - H2450-049-0
Benefit Details
|
Yellow Medicine |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 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 Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Aurora |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Beadle |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Bennett |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 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 Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Bon Homme |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Brookings |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Brown |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 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 Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Brule |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Buffalo |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Butte |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 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 Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Campbell |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Charles Mix |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Clark |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 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 Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Clay |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Codington |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Corson |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 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 Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Custer |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Davison |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Day |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 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 Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Deuel |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Dewey |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Douglas |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 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 Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Edmunds |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Fall River |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Faulk |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 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 Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Grant |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Gregory |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Haakon |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 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 Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Hamlin |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Hand |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Hanson |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 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 Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Harding |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Hughes |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Hutchinson |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 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 Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Hyde |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Jackson |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Jerauld |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 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 Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Jones |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Kingsbury |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Lake |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 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 Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Lawrence |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Lincoln |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Lyman |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 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 Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
McCook |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
McPherson |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Marshall |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 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 Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Meade |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Mellette |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Miner |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 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 Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Minnehaha |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Moody |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Oglala Lakota |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 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 Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Pennington |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Perkins |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Potter |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 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 Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Roberts |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Sanborn |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Spink |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 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 Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Stanley |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Sully |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Todd |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 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 Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Tripp |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Turner |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Union |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 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 Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Walworth |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Yankton |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medica Prime Solution Standard w/Rx (Cost) in SD - H2450-049-0
Benefit Details
|
Ziebach |
$49.40 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
-- |
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|