BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Arkansas |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Ashley |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Baxter |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Benton |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Boone |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Bradley |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Calhoun |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Carroll |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Clark |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Clay |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Cleburne |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Cleveland |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Columbia |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Conway |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Craighead |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Crawford |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Crittenden |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Cross |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Dallas |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Drew |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Faulkner |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Franklin |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Fulton |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Garland |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Grant |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Greene |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Hempstead |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Hot Spring |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Independence |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Izard |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Jackson |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Jefferson |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Johnson |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Lawrence |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Lee |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Lincoln |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Logan |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Lonoke |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Madison |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Marion |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Mississippi |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Monroe |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Montgomery |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Nevada |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Newton |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Ouachita |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Perry |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Pike |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Poinsett |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Polk |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Pope |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Prairie |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Pulaski |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Randolph |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
St. Francis |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Saline |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Scott |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Searcy |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Sebastian |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Sharp |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Stone |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Union |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Van Buren |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Washington |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
White |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Woodruff |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
BlueMedicare Value Choice (PPO) in AR - H3554-004-0
Benefit Details
|
Yell |
$29.00 |
$150 Tier 1, 2, 3 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $13.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,000 Browse Formulary |
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