PriorityMedicare Ideal (PPO) in MI - H4875-018-1
Benefits & Contact Info
|
Allegan |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-1
Benefits & Contact Info
|
Barry |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-1
Benefits & Contact Info
|
Kent |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Ideal (PPO) in MI - H4875-018-1
Benefits & Contact Info
|
Lenawee |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-1
Benefits & Contact Info
|
Ottawa |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefits & Contact Info
|
Berrien |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefits & Contact Info
|
Calhoun |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefits & Contact Info
|
Cass |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefits & Contact Info
|
Ionia |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefits & Contact Info
|
Isabella |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefits & Contact Info
|
Kalamazoo |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefits & Contact Info
|
Mason |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefits & Contact Info
|
Midland |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefits & Contact Info
|
Missaukee |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefits & Contact Info
|
Montcalm |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefits & Contact Info
|
Muskegon |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefits & Contact Info
|
Newaygo |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefits & Contact Info
|
Oceana |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefits & Contact Info
|
Osceola |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefits & Contact Info
|
Otsego |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefits & Contact Info
|
St. Clair |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefits & Contact Info
|
Van Buren |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-2
Benefits & Contact Info
|
Wexford |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefits & Contact Info
|
Alcona |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefits & Contact Info
|
Antrim |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefits & Contact Info
|
Benzie |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefits & Contact Info
|
Charlevoix |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefits & Contact Info
|
Clare |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefits & Contact Info
|
Crawford |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefits & Contact Info
|
Grand Traverse |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefits & Contact Info
|
Hillsdale |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefits & Contact Info
|
Lake |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefits & Contact Info
|
Lapeer |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefits & Contact Info
|
Leelanau |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefits & Contact Info
|
Manistee |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefits & Contact Info
|
Mecosta |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Ideal (PPO) in MI - H4875-018-3
Benefits & Contact Info
|
Monroe |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefits & Contact Info
|
Alpena |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefits & Contact Info
|
Cheboygan |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefits & Contact Info
|
Eaton |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefits & Contact Info
|
Emmet |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefits & Contact Info
|
Gladwin |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefits & Contact Info
|
Gratiot |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefits & Contact Info
|
Iosco |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefits & Contact Info
|
Jackson |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefits & Contact Info
|
Kalkaska |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefits & Contact Info
|
Montmorency |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefits & Contact Info
|
Oscoda |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefits & Contact Info
|
Presque Isle |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefits & Contact Info
|
Roscommon |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefits & Contact Info
|
St. Joseph |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefits & Contact Info
|
Sanilac |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-4
Benefits & Contact Info
|
Shiawassee |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-5
Benefits & Contact Info
|
Arenac |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Ideal (PPO) in MI - H4875-018-5
Benefits & Contact Info
|
Bay |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-5
Benefits & Contact Info
|
Branch |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-5
Benefits & Contact Info
|
Clinton |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Ideal (PPO) in MI - H4875-018-5
Benefits & Contact Info
|
Genesee |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-5
Benefits & Contact Info
|
Huron |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-5
Benefits & Contact Info
|
Ingham |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Ideal (PPO) in MI - H4875-018-5
Benefits & Contact Info
|
Livingston |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-5
Benefits & Contact Info
|
Macomb |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-5
Benefits & Contact Info
|
Oakland |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Ideal (PPO) in MI - H4875-018-5
Benefits & Contact Info
|
Ogemaw |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-5
Benefits & Contact Info
|
Saginaw |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-5
Benefits & Contact Info
|
Tuscola |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
PriorityMedicare Ideal (PPO) in MI - H4875-018-5
Benefits & Contact Info
|
Washtenaw |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PriorityMedicare Ideal (PPO) in MI - H4875-018-5
Benefits & Contact Info
|
Wayne |
$19.00 |
$125 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 30%
all covered insulin pay $35 or less | $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|