Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
Benefit Details
|
Alfalfa |
$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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
Benefit Details
|
Blaine |
$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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
Benefit Details
|
Bryan |
$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 | $6,900 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 OK - H4801-021-0
Benefit Details
|
Caddo |
$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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
Benefit Details
|
Canadian |
$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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
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 | $6,900 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 OK - H4801-021-0
Benefit Details
|
Cleveland |
$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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
Benefit Details
|
Cotton |
$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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
Benefit Details
|
Creek |
$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 | $6,900 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 OK - H4801-021-0
Benefit Details
|
Dewey |
$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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
Benefit Details
|
Garfield |
$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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
Benefit Details
|
Garvin |
$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 | $6,900 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 OK - H4801-021-0
Benefit Details
|
Grady |
$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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
Benefit Details
|
Grant |
$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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
Benefit Details
|
Greer |
$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 | $6,900 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 OK - H4801-021-0
Benefit Details
|
Harmon |
$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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
Benefit Details
|
Hughes |
$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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
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 | $6,900 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 OK - H4801-021-0
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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
Benefit Details
|
Kay |
$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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
Benefit Details
|
Kingfisher |
$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 | $6,900 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 OK - H4801-021-0
Benefit Details
|
Kiowa |
$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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
Benefit Details
|
Lincoln |
$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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
Benefit Details
|
Logan |
$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 | $6,900 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 OK - H4801-021-0
Benefit Details
|
McClain |
$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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
Benefit Details
|
McIntosh |
$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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
Benefit Details
|
Major |
$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 | $6,900 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 OK - H4801-021-0
Benefit Details
|
Marshall |
$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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
Benefit Details
|
Mayes |
$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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
Benefit Details
|
Muskogee |
$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 | $6,900 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 OK - H4801-021-0
Benefit Details
|
Noble |
$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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
Benefit Details
|
Okfuskee |
$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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
Benefit Details
|
Oklahoma |
$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 | $6,900 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 OK - H4801-021-0
Benefit Details
|
Okmulgee |
$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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
Benefit Details
|
Osage |
$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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
Benefit Details
|
Pawnee |
$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 | $6,900 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 OK - H4801-021-0
Benefit Details
|
Payne |
$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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
Benefit Details
|
Pittsburg |
$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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
Benefit Details
|
Pottawatomie |
$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 | $6,900 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 OK - H4801-021-0
Benefit Details
|
Seminole |
$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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
Benefit Details
|
Stephens |
$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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
Benefit Details
|
Tillman |
$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 | $6,900 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 OK - H4801-021-0
Benefit Details
|
Tulsa |
$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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Cross Medicare Advantage Dental Premier (PPO) in OK - H4801-021-0
Benefit Details
|
Wagoner |
$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 | $6,900 Browse Formulary |
|
new |
new |
Higher cost-sharing at standard network pharmacies. Details:
|