Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Adams |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Barnes |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Benson |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 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 |
Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Billings |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Bowman |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Cass |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 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 |
Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Cavalier |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Dickey |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Dunn |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 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 |
Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Eddy |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Emmons |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Foster |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 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 |
Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Grant |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Griggs |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Hettinger |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 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 |
Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Kidder |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
LaMoure |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Logan |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 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 |
Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
McHenry |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
McIntosh |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
McLean |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 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 |
Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Mercer |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Nelson |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Oliver |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 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 |
Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Pembina |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Pierce |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Ramsey |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 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 |
Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Ransom |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Richland |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Rolette |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 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 |
Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Sargent |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Sheridan |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Sioux |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 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 |
Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Slope |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Stark |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Steele |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 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 |
Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Towner |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Traill |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Walsh |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 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 |
Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Ward |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Wells |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in ND - H2450-037-0
Benefits & Contact Info
|
Williams |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 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 |
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Aurora |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Beadle |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Bennett |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 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 |
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Bon Homme |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Brown |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Brule |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 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 |
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Buffalo |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Butte |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Campbell |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Charles Mix |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Clark |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Clay |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Codington |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Corson |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Custer |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Davison |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Day |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Dewey |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Douglas |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Edmunds |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Fall River |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Faulk |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Grant |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Gregory |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Haakon |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Hand |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Hanson |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Harding |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Hughes |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Hutchinson |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Hyde |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Jackson |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Jerauld |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Jones |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Kingsbury |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Lake |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Lawrence |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Lincoln |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Lyman |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
McCook |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
McPherson |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Marshall |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Meade |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Mellette |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Miner |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Minnehaha |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Moody |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Oglala Lakota |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Pennington |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Perkins |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Potter |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Roberts |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Sanborn |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Spink |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Stanley |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Sully |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Todd |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Tripp |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
-- |
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Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
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Turner |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Union |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 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 |
Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Walworth |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Yankton |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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Medica Prime Solution Premier w/Rx (Cost) in SD - H2450-037-0
Benefits & Contact Info
|
Ziebach |
$264.70 |
$545 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: 50% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
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