Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Anderson |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Aransas |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Archer |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Austin |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Bee |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Bell |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Bexar |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Blanco |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Bosque |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Bowie |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Brazoria |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Brazos |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Brooks |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Burleson |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Calhoun |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Cameron |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Camp |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Cass |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Cherokee |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Clay |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Collin |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Coryell |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Dallas |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Delta |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Denton |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
DeWitt |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Dimmit |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Duval |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Ellis |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
El Paso |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Erath |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Falls |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Fort Bend |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Franklin |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Freestone |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Galveston |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Goliad |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Grayson |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Gregg |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Grimes |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Hamilton |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Harris |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Harrison |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Henderson |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Hidalgo |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Hopkins |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Houston |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Hudspeth |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Hunt |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Jack |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Jackson |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Jefferson |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Jim Hogg |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Jim Wells |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Karnes |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Kaufman |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Kenedy |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Kleberg |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Lamar |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
La Salle |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Lavaca |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Leon |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Liberty |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Limestone |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
McCulloch |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
McLennan |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Madison |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Mason |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Maverick |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Mills |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Montgomery |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Morris |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Nacogdoches |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Nueces |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Orange |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Palo Pinto |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Panola |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Parker |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Polk |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Potter |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Rains |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Randall |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Refugio |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Robertson |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Rusk |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
San Jacinto |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
San Patricio |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
San Saba |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Shackelford |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Shelby |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Smith |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Somervell |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Starr |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Tarrant |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Throckmorton |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Titus |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Tom Green |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Travis |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Trinity |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Tyler |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Upshur |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Uvalde |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Van Zandt |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Victoria |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Walker |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Waller |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Washington |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Webb |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Willacy |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Williamson |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Wise |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
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 |
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Wood |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Young |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in TX - H4801-016-0
Benefit Details
|
Zavala |
$0.00 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $44.00 Non-Preferred Drug: $85.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|