MVP SmartFund (MSA) - H5613-002-0
Benefit Details
|
Montgomery |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | n/a |
|
|
|
|
Aetna Medicare Credit Plan (PPO) - H5521-313-0
Benefit Details
|
Montgomery |
$0.00 |
$350 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare Eagle Plan (PPO) - H5521-323-0
Benefit Details
|
Montgomery |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $7,550 |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Aetna Medicare Elite Plan (PPO) - H5521-119-0
Benefit Details
|
Montgomery |
$0.00 |
$250 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare Value Plan (HMO-POS) - H3312-062-0
Benefit Details
|
Montgomery |
$0.00 |
$300 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
CDPHP $0 Medicare Rx (HMO) - H3388-014-0
Benefit Details
|
Montgomery |
$0.00 |
$300 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $17.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
select insulin pay $35 copay | $7,500 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
CDPHP Flex (PPO) - H5042-012-0
Benefit Details
|
Montgomery |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $5,500 |
|
|
|
|
CDPHP Vital Rx (PPO) - H5042-009-0
Benefit Details
|
Montgomery |
$0.00 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $17.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
select insulin pay $35 copay | $7,500 Browse Formulary |
|
|
|
|
Highmark Blue Shield Freedom (HMO) - H3384-066-0
Benefit Details
|
Montgomery |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $5,000 |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Highmark Blue Shield Freedom Basic (PPO) - H5526-022-0
Benefit Details
|
Montgomery |
$0.00 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $14.00 Preferred Brand: $42.00 Non-Preferred Drug: $94.00 Specialty Tier: 27%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Highmark Blue Shield Freedom Nation (PPO) - H5526-021-0
Benefit Details
|
Montgomery |
$0.00 |
$325 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $94.00 Specialty Tier: 27%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Highmark Blue Shield Freedom Value (HMO) - H3384-063-0
Benefit Details
|
Montgomery |
$0.00 |
$295 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $94.00 Specialty Tier: 28%
select insulin pay $35 copay | $7,550 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 |
Humana Gold Plus H3533-006 (HMO) - H3533-006-0
Benefit Details
|
Montgomery |
$0.00 |
$300 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin pay $35 copay | $7,200 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Humana Honor (PPO) - H5970-016-0
Benefit Details
|
Montgomery |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,500 |
|
|
|
|
HumanaChoice H5970-015 (PPO) - H5970-015-0
Benefit Details
|
Montgomery |
$0.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin pay $35 copay | $4,900 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 |
HumanaChoice H5970-018 (PPO) - H5970-018-0
Benefit Details
|
Montgomery |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 27%
select insulin pay $35 copay | $4,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Medicare BlueBasic (PPO) - H3335-044-0
Benefit Details
|
Montgomery |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,500 |
|
|
|
|
MediGold Essential Care (HMO) - H9827-001-0
Benefit Details
|
Montgomery |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $6,200 Browse Formulary |
new |
new |
new |
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
MVP Medicare WellSelect with Part D (PPO) - H9615-008-0
Benefit Details
|
Montgomery |
$0.00 |
$300 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: 25% Specialty Tier: 27%
| $7,550 Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Advantage Patriot (Regional PPO) - R5342-002-0
Benefit Details
|
Montgomery |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $6,700 |
|
|
|
|
Wellcare Advantage No Premium (PFFS) - H2816-038-0
Benefit Details
|
Montgomery |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | n/a |
|
-- |
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Wellcare Fidelis No Premium (HMO) - H5599-004-0
Benefit Details
|
Montgomery |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $37.00 Non-Preferred Drug: 42% Specialty Tier: 33% Select Care Drugs: $0.00
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Giveback Open (PPO) - H2775-111-0
Benefit Details
|
Montgomery |
$0.00 |
$325 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 48% Specialty Tier: 27% Select Care Drugs: $0.00
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare No Premium Open (PPO) - H2775-106-0
Benefit Details
|
Montgomery |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 42% Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 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 |
UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO) - R5342-001-0
Benefit Details
|
Montgomery |
$16.00 |
$300 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | $7,200 Browse Formulary |
|
|
|
|
Wellcare Fidelis Assist (HMO-POS) - H5599-002-0
Benefit Details
|
Montgomery |
$17.10 |
$480 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: 22% Non-Preferred Drug: 37% Specialty Tier: 25% Select Care Drugs: $0.00
| $7,550 Browse Formulary |
|
|
|
|
MediGold Medical Only (HMO) - H9827-003-0
Benefit Details
|
Montgomery |
$19.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,800 |
new |
new |
new |
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice SNP-DE H5970-020 (PPO D-SNP) - H5970-020-0
Benefit Details
|
Montgomery |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $19.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Fidelis Dual Access (HMO D-SNP) - H5599-001-0
Benefit Details
|
Montgomery |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: 33% Specialty Tier: 25% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
|
Wellcare Fidelis Dual Plus (HMO D-SNP) - H5599-008-0
Benefit Details
|
Montgomery |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: 33% Specialty Tier: 25% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Aetna Medicare Assure Plan (HMO D-SNP) - H3312-070-0
Benefit Details
|
Montgomery |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $47.00 Non-Preferred Drug: 25% Specialty Tier: 25%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5970-019 (PPO) - H5970-019-0
Benefit Details
|
Montgomery |
$24.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Humana Gold Plus H3533-013 (HMO) - H3533-013-0
Benefit Details
|
Montgomery |
$26.00 |
$275 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin pay $35 copay | $6,700 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 |
MediGold True Advantage (HMO) - H9827-002-0
Benefit Details
|
Montgomery |
$29.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $5,500 Browse Formulary |
new |
new |
new |
|
Humana Gold Plus SNP-DE H3533-002 (HMO D-SNP) - H3533-002-0
Benefit Details
|
Montgomery |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Assist Open (PPO) - H2775-113-0
Benefit Details
|
Montgomery |
$30.70 |
$480 Tier 1 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $45.00 Non-Preferred Drug: 44% Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
CDPHP Basic RX (HMO) - H3388-013-0
Benefit Details
|
Montgomery |
$31.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $15.00 Preferred Brand: $45.00 Non-Preferred Drug: $97.00 Specialty Tier: 33%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
|
Empire MediBlue Dual Advantage (HMO D-SNP) - H8432-039-2
Benefit Details
|
Montgomery |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
Some Generics | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Dual Access Open (PPO D-SNP) - H2775-112-0
Benefit Details
|
Montgomery |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: 49% Specialty Tier: 25% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare Dual Complete Plan 2 (HMO D-SNP) - H3387-015-1
Benefit Details
|
Montgomery |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00
| n/a Browse Formulary |
|
|
|
|
CDPHP Choice (HMO) - H3388-001-0
Benefit Details
|
Montgomery |
$39.90 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $5,000 |
|
|
|
|
MVP Medicare Secure with Part D (HMO-POS) - H3305-032-0
Benefit Details
|
Montgomery |
$40.00 |
$150 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: 25% Specialty Tier: 30%
| $7,550 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
CDPHP Flex Rx (PPO) - H5042-011-0
Benefit Details
|
Montgomery |
$42.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $14.00 Preferred Brand: $44.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
select insulin pay $35 copay | $5,500 Browse Formulary |
|
|
|
|
Empire MediBlue Plus (HMO) - H8432-038-2
Benefit Details
|
Montgomery |
$42.00 |
$325 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $37.00 Non-Preferred Drug: $95.00 Specialty Tier: 27%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Hamaspik Medicare Select (HMO D-SNP) - H0034-001-0
Benefit Details
|
Montgomery |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 15%
| n/a Browse Formulary |
|
new |
new |
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare Dual Complete Plan 1 (HMO D-SNP) - H3387-014-1
Benefit Details
|
Montgomery |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00
| n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP) - H2292-001-0
Benefit Details
|
Montgomery |
$42.40 |
$480 |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 25%
| n/a Browse Formulary |
|
-- |
|
|
UnitedHealthcare Medicare Advantage Choice Plan 3 (Regional PPO) - R5342-005-0
Benefit Details
|
Montgomery |
$46.00 |
$250 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
select insulin coverage $35 or less | $6,900 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Aetna Medicare Premier Plan (PPO) - H5521-110-0
Benefit Details
|
Montgomery |
$50.00 |
$250 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Enhanced (PFFS) - H2816-019-0
Benefit Details
|
Montgomery |
$55.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Generic: $7.00 Preferred Brand: $37.00 Non-Preferred Drug: 48% Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Highmark Blue Shield Freedom Plus (HMO) - H3384-059-0
Benefit Details
|
Montgomery |
$57.00 |
$275 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $42.00 Non-Preferred Drug: $94.00 Specialty Tier: 28%
select insulin pay $35 copay | $6,700 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 |
CDPHP Value Rx (HMO) - H3388-004-0
Benefit Details
|
Montgomery |
$60.80 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $13.00 Preferred Brand: $42.00 Non-Preferred Drug: $93.00 Specialty Tier: 33%
select insulin pay $35 copay | $5,800 Browse Formulary |
|
|
|
|
MVP Medicare Preferred Gold without Part D (HMO-POS) - H3305-020-0
Benefit Details
|
Montgomery |
$62.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $7,550 |
|
|
|
|
Wellcare Advantage Premium Enhanced (PFFS) - H2816-037-0
Benefit Details
|
Montgomery |
$62.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | n/a |
|
-- |
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UnitedHealthcare Medicare Advantage Choice Plan 4 (Regional PPO) - R5342-006-0
Benefit Details
|
Montgomery |
$84.00 |
$150 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
select insulin coverage $35 or less | $6,700 Browse Formulary |
|
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Empire MediBlue Access (PPO) - H3342-023-2
Benefit Details
|
Montgomery |
$90.00 |
$310 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $10.00 Preferred Brand: $38.00 Non-Preferred Drug: $88.00 Specialty Tier: 27% Select Care Drugs: $0.00
| $6,200 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
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MVP Medicare Secure Plus with Part D (HMO-POS) - H3305-022-0
Benefit Details
|
Montgomery |
$90.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $45.00 Non-Preferred Drug: 27% Specialty Tier: 33%
| $7,550 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 |
Medicare BluePlus (PPO) - H3335-018-0
Benefit Details
|
Montgomery |
$116.00 |
$480 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $12.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 35% Specialty Tier: 25%
| $6,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Premium Ultra Open (PPO) - H2775-105-0
Benefit Details
|
Montgomery |
$121.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 43% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
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Highmark Blue Shield Senior Blue 652 (HMO) - H3384-013-0
Benefit Details
|
Montgomery |
$124.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $94.00 Specialty Tier: 33%
select insulin pay $35 copay | $6,700 Browse Formulary |
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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 |
MVP Medicare WellSelect Plus with Part D (PPO) - H9615-007-0
Benefit Details
|
Montgomery |
$125.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Drug: 26% Specialty Tier: 33%
| $6,500 Browse Formulary |
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CDPHP Choice Rx (HMO) - H3388-002-0
Benefit Details
|
Montgomery |
$131.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $11.00 Preferred Brand: $40.00 Non-Preferred Drug: $90.00 Specialty Tier: 33%
select insulin pay $35 copay | $5,000 Browse Formulary |
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MVP Medicare Preferred Gold with Part D (HMO-POS) - H3305-021-0
Benefit Details
|
Montgomery |
$140.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Drug: 27% Specialty Tier: 33%
| $5,800 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 |
Wellcare Premium Ultra (PFFS) - H2816-013-0
Benefit Details
|
Montgomery |
$156.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: 42% Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
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Highmark Blue Shield Forever Blue 770 (PPO) - H5526-018-0
Benefit Details
|
Montgomery |
$201.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $94.00 Specialty Tier: 33%
select insulin pay $35 copay | $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
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