Lasso Healthcare Growth (MSA) - H1924-001-0
Benefit Details
|
Polk |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | n/a |
|
|
|
|
Lasso Healthcare Growth Plus (MSA) - H1924-004-0
Benefit Details
|
Polk |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | n/a |
|
|
|
|
AARP Medicare Advantage (HMO-POS) - H1045-028-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $45.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $4,000 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
AARP Medicare Advantage Choice (PPO) - H2406-011-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $4,900 Browse Formulary |
|
|
|
|
AARP Medicare Advantage Choice Plan 2 (Regional PPO) - R0759-001-0
Benefit Details
|
Polk |
$0.00 |
$195 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: 30%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
|
|
|
|
AARP Medicare Advantage Focus (HMO-POS) - H1045-045-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $45.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $2,900 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
AARP Medicare Advantage Patriot (Regional PPO) - R0759-002-0
Benefit Details
|
Polk |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $6,700 |
|
|
|
|
Advantage Care by Ultimate (HMO C-SNP) - H2962-051-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Drug: $65.00 Specialty Tier: 33% Select Care Drugs: $10.00
all covered insulin pay $35 or less | n/a Browse Formulary |
|
|
|
|
Advantage Care COPD by Ultimate (HMO C-SNP) - H2962-034-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Generic: $0.00 Preferred Brand: $20.00 Non-Preferred Drug: $60.00 Specialty Tier: 33% Select Care Drugs: $10.00
all covered insulin pay $35 or less | 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 Choice (HMO-POS) - H1609-028-0
Benefit Details
|
Polk |
$0.00 |
$195 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: 30%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare Eagle (PPO) - H5521-308-0
Benefit Details
|
Polk |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $5,500 |
|
|
|
|
Aetna Medicare Premier (PPO) - H5521-033-0
Benefit Details
|
Polk |
$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%
all covered insulin pay $35 or less | $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 |
Aetna Medicare Premier Plus (PPO) - H5521-270-0
Benefit Details
|
Polk |
$0.00 |
$150 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: 30%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare Select (HMO) - H1609-022-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $10.00 Non-Preferred Drug: $90.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $2,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
BayCarePlus Complete (HMO) - H2235-001-0
Benefit Details
|
Polk |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $3.00 Preferred Brand: $35.00 Non-Preferred Brand: $85.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $3,100 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
BayCarePlus Rewards (HMO) - H2235-002-0
Benefit Details
|
Polk |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $4,500 Browse Formulary |
|
|
|
|
BlueMedicare Classic (HMO) - H1035-021-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: $93.00 Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $4,900 Browse Formulary |
|
|
|
|
BlueMedicare Premier (HMO) - H1035-023-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Drug: $80.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $1,900 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
BlueMedicare Saver (HMO) - H1035-037-0
Benefit Details
|
Polk |
$0.00 |
$50 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 32% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,700 Browse Formulary |
|
|
|
|
BlueMedicare Value (PPO) - H5434-034-0
Benefit Details
|
Polk |
$0.00 |
$150 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $4,000 Browse Formulary |
|
|
|
|
CareBreeze (HMO C-SNP) - H1019-116-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: $85.00 Specialty Tier: 33%
all covered insulin pay $35 or less | 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 |
CareBreeze Platinum (HMO C-SNP) - H1019-125-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $40.00 Non-Preferred Drug: $70.00 Specialty Tier: 33%
all covered insulin pay $35 or less | n/a Browse Formulary |
|
|
|
|
CareComplete (HMO C-SNP) - H1019-107-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Drug: $85.00 Specialty Tier: 33%
all covered insulin pay $35 or less | n/a Browse Formulary |
|
|
|
|
CareComplete Platinum (HMO C-SNP) - H1019-122-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $40.00 Non-Preferred Drug: $70.00 Specialty Tier: 33%
all covered insulin pay $35 or less | 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 |
CareFree (HMO) - H1019-104-1
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $35.00 Non-Preferred Drug: $60.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $3,000 Browse Formulary |
|
|
|
|
CareOne Plus (HMO) - H1019-103-1
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $5.00 Non-Preferred Drug: $45.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $1,600 Browse Formulary |
|
|
|
|
CareSalute (HMO) - H1019-132-0
Benefit Details
|
Polk |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,900 |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Cigna Preferred Medicare (HMO) - H5410-024-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $2,700 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Cigna Preferred Savings Medicare (HMO) - H5410-026-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $3,700 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Cigna True Choice Medicare (PPO) - H7849-017-0
Benefit Details
|
Polk |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $4,950 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 |
Devoted CHOICE GIVEBACK Polk (PPO) - H9884-006-0
Benefit Details
|
Polk |
$0.00 |
$150 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: 30%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
|
new |
new |
|
Devoted CORE Tampa (HMO) - H1290-036-2
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $8.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $2,900 Browse Formulary |
|
|
|
|
Devoted ESSENTIALS Tampa (HMO) - H1290-051-2
Benefit Details
|
Polk |
$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%
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Freedom Platinum Plan Rx (HMO) - H5427-092-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Preferred Brand: $10.00 Non-Preferred Drug: $55.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $1,750 Browse Formulary |
|
|
|
|
Freedom Platinum Rewards Plan Rx (HMO) - H5427-107-0
Benefit Details
|
Polk |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Preferred Brand: $30.00 Non-Preferred Drug: $60.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
|
Freedom Savings Plan (HMO) - H5427-052-0
Benefit Details
|
Polk |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,400 |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Freedom VIP Care (HMO C-SNP) - H5427-070-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Preferred Brand: $15.00 Non-Preferred Drug: $55.00 Specialty Tier: 33% Select Diabetic Drugs: $0.00
all covered insulin pay $35 or less | n/a Browse Formulary |
|
|
|
|
Freedom VIP Rewards (HMO C-SNP) - H5427-099-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Preferred Brand: $30.00 Non-Preferred Drug: $60.00 Specialty Tier: 33% Select Diabetic Drugs: $10.00
all covered insulin pay $35 or less | n/a Browse Formulary |
|
|
|
|
Freedom VIP Savings (HMO C-SNP) - H5427-072-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Drug: $65.00 Specialty Tier: 33% Select Diabetic Drugs: $10.00
all covered insulin pay $35 or less | 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 |
Freedom VIP Savings COPD (HMO C-SNP) - H5427-077-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Preferred Brand: $20.00 Non-Preferred Drug: $60.00 Specialty Tier: 33%
all covered insulin pay $35 or less | n/a Browse Formulary |
|
|
|
|
Humana Gold Plus - Diabetes and Heart (HMO C-SNP) - H1036-296-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $35.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | n/a Browse Formulary |
|
|
|
|
Humana Gold Plus H1036-230 (HMO) - H1036-230-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $30.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $2,400 Browse Formulary |
|
|
|
|
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 H1036-268 (HMO) - H1036-268-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $45.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $4,000 Browse Formulary |
|
|
|
|
Humana Honor (HMO) - H1036-289-0
Benefit Details
|
Polk |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $6,700 |
|
|
|
|
Humana Honor (PPO) - H5216-257-0
Benefit Details
|
Polk |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $5,100 |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice Florida H5216-072 (PPO) - H5216-072-0
Benefit Details
|
Polk |
$0.00 |
$150 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $4,900 Browse Formulary |
|
|
|
|
HumanaChoice Florida H5216-304 (PPO) - H5216-304-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $4,700 Browse Formulary |
|
|
|
|
HumanaChoice R5826-018 (Regional PPO) - R5826-018-0
Benefit Details
|
Polk |
$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 |
Molina Medicare Choice Care (HMO) - H8130-010-0
Benefit Details
|
Polk |
$0.00 |
$125 Tier 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $8,300 Browse Formulary |
|
-- |
|
|
Molina Medicare Choice Care Select (HMO) - H8130-011-0
Benefit Details
|
Polk |
$0.00 |
$450 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $15.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25% Select Care Drugs: $5.00
all covered insulin pay $35 or less | $8,300 Browse Formulary |
|
-- |
|
|
Molina Medicare Connect Care (HMO C-SNP) - H8130-008-0
Benefit Details
|
Polk |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $45.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | 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 |
Optimum Diamond Savings (HMO C-SNP) - H5594-030-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Preferred Brand: $30.00 Non-Preferred Drug: $80.00 Specialty Tier: 33% Select Diabetic Drugs: $10.00
all covered insulin pay $35 or less | n/a Browse Formulary |
|
|
|
|
Optimum Diamond Savings COPD (HMO C-SNP) - H5594-031-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Preferred Brand: $30.00 Non-Preferred Drug: $80.00 Specialty Tier: 33%
all covered insulin pay $35 or less | n/a Browse Formulary |
|
|
|
|
Optimum Gold Plan (HMO) - H5594-019-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Preferred Brand: $35.00 Non-Preferred Drug: $85.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $3,400 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Premier by Ultimate (HMO) - H2962-045-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Drug: $60.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $2,800 Browse Formulary |
|
|
|
|
Simply Care (HMO I-SNP) - H5471-092-0
Benefit Details
|
Polk |
$0.00 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $5.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
all covered insulin pay $35 or less | n/a Browse Formulary |
|
|
|
|
Simply Comfort (HMO I-SNP) - H5471-093-0
Benefit Details
|
Polk |
$0.00 |
$505 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
all covered insulin pay $35 or less | 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 |
Simply Extra (HMO) - H5471-106-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $3,450 Browse Formulary |
|
|
|
|
Simply Freedom (PPO) - H9469-008-0
Benefit Details
|
Polk |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $5,000 Browse Formulary |
new |
new |
new |
|
Simply Freedom Extra (PPO) - H9469-005-0
Benefit Details
|
Polk |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $6,100 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 |
Simply Level (HMO C-SNP) - H5471-070-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $0.00 Non-Preferred Brand: $40.00 Specialty Tier: 33%
all covered insulin pay $35 or less | n/a Browse Formulary |
|
|
|
|
Simply More (HMO) - H5471-071-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $10.00 Non-Preferred Brand: $55.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $3,450 Browse Formulary |
|
|
|
|
UnitedHealthcare Medicare Advantage Walgreens (HMO-POS C-SNP) - H1045-048-3
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | n/a 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 |
Wellcare Giveback (HMO) - H1032-200-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Drug: $70.00 Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $2,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare No Premium (HMO) - H1032-201-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $0.00 Non-Preferred Drug: $65.00 Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $1,200 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare No Premium Open (PPO) - H5199-012-0
Benefit Details
|
Polk |
$0.00 |
$100 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 31% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,400 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 |
Wellcare Specialty Giveback (HMO C-SNP) - H1032-203-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $0.00 Non-Preferred Drug: $70.00 Specialty Tier: 33% Select Diabetic Drugs: $0.00
all covered insulin pay $35 or less | n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Specialty No Premium (HMO C-SNP) - H1032-184-0
Benefit Details
|
Polk |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $0.00 Non-Preferred Drug: $65.00 Specialty Tier: 33% Select Diabetic Drugs: $0.00
all covered insulin pay $35 or less | n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice R5826-074 (Regional PPO) - R5826-074-0
Benefit Details
|
Polk |
$4.00 |
$395 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
all covered insulin pay $35 or less | $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 |
CareNeeds Plus (HMO D-SNP) - H1019-026-0
Benefit Details
|
Polk |
$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: $3.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | n/a Browse Formulary |
|
|
|
|
Cigna Primary Medicare (HMO) - H5410-033-0
Benefit Details
|
Polk |
$17.20 |
$505 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $18.00 Preferred Brand: 20% Non-Preferred Drug: 43% Specialty Tier: 25%
all covered insulin pay $35 or less | $3,500 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Wellcare Dual Access Open (PPO D-SNP) - H5199-016-0
Benefit Details
|
Polk |
$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
all covered insulin pay $35 or less | 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 |
Cigna TotalCare (HMO D-SNP) - H5410-046-0
Benefit Details
|
Polk |
$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%
all covered insulin pay $35 or less | n/a Browse Formulary |
|
-- |
|
|
Cigna TotalCare Plus (HMO D-SNP) - H5410-025-0
Benefit Details
|
Polk |
$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
all covered insulin pay $35 or less | n/a Browse Formulary |
|
-- |
|
|
Humana Gold Plus SNP-DE H1036-231 (HMO D-SNP) - H1036-231-0
Benefit Details
|
Polk |
$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: $6.00 Generic: $18.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | 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 (HMO D-SNP) - H1609-019-0
Benefit Details
|
Polk |
$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: $6.00 Generic: $11.00 Preferred Brand: 25% Non-Preferred Drug: 35% Specialty Tier: 25%
all covered insulin pay $35 or less | n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Humana Fully Integrated H1036-280 (HMO D-SNP) - H1036-280-0
Benefit Details
|
Polk |
$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: $1.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | n/a Browse Formulary |
|
|
|
|
Aetna Medicare Assure Plus (HMO D-SNP) - H1609-049-0
Benefit Details
|
Polk |
$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: $6.00 Generic: $11.00 Preferred Brand: 25% Non-Preferred Drug: 35% Specialty Tier: 25%
all covered insulin pay $35 or less | n/a 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 |
Devoted DUAL Tampa (HMO D-SNP) - H1290-024-0
Benefit Details
|
Polk |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
Yes, some additional gap coverage. | Preferred Generic: 25% Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25%
all covered insulin pay $35 or less | n/a Browse Formulary |
|
|
|
|
Devoted PRIME (HMO) - H1290-037-5
Benefit Details
|
Polk |
$32.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25%
all covered insulin pay $35 or less | $2,900 Browse Formulary |
|
|
|
|
Wellcare Dual Reserve (HMO D-SNP) - H1032-202-0
Benefit Details
|
Polk |
$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%
all covered insulin pay $35 or less | 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 |
BayCarePlus Premier (HMO) - H2235-003-0
Benefit Details
|
Polk |
$34.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $30.00 Non-Preferred Brand: $85.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $2,500 Browse Formulary |
|
|
|
|
Molina Medicare Complete Care Select (HMO D-SNP) - H8130-009-0
Benefit Details
|
Polk |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: 36% Specialty Tier: 25%
all covered insulin pay $35 or less | n/a Browse Formulary |
|
-- |
|
|
Advantage Plus by Ultimate (Full) (HMO D-SNP) - H2962-035-0
Benefit Details
|
Polk |
$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 | Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25% Supplemental Drugs: $0.00
all covered insulin pay $35 or less | 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 |
Advantage Plus by Ultimate (Partial) (HMO D-SNP) - H2962-036-0
Benefit Details
|
Polk |
$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 | Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25% Supplemental Drugs: $0.00
all covered insulin pay $35 or less | n/a Browse Formulary |
|
|
|
|
BlueMedicare Complete (HMO D-SNP) - H1035-030-0
Benefit Details
|
Polk |
$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: 25% Generic: 25% Preferred Brand: 25% Non-Preferred Drug: 25% Specialty Tier: 25%
all covered insulin pay $35 or less | n/a Browse Formulary |
|
|
|
|
Florida Complete Care (HMO I-SNP) - H9986-001-0
Benefit Details
|
Polk |
$35.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 25%
all covered insulin pay $35 or less | 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 |
Florida Complete Care- In The Community (HMO I-SNP) - H9986-002-0
Benefit Details
|
Polk |
$35.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 25%
all covered insulin pay $35 or less | n/a Browse Formulary |
|
new |
new |
|
Freedom Medi-Medi Full (HMO D-SNP) - H5427-087-0
Benefit Details
|
Polk |
$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: $15.00 Preferred Brand: $45.00 Non-Preferred Drug: $95.00 Specialty Tier: 25%
all covered insulin pay $35 or less | n/a Browse Formulary |
|
|
|
|
Freedom Medi-Medi Partial (HMO D-SNP) - H5427-078-0
Benefit Details
|
Polk |
$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: $15.00 Preferred Brand: $45.00 Non-Preferred Drug: $95.00 Specialty Tier: 25%
all covered insulin pay $35 or less | 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 |
Longevity Health Plan (HMO I-SNP) - H1644-001-0
Benefit Details
|
Polk |
$35.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 25%
all covered insulin pay $35 or less | n/a Browse Formulary |
|
-- |
|
|
Molina Medicare Complete Care (HMO D-SNP) - H8130-001-0
Benefit Details
|
Polk |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: 35% Specialty Tier: 25%
all covered insulin pay $35 or less | n/a Browse Formulary |
|
-- |
|
|
Optimum Emerald Full (HMO D-SNP) - H5594-017-0
Benefit Details
|
Polk |
$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: $15.00 Preferred Brand: $45.00 Non-Preferred Drug: $95.00 Specialty Tier: 25%
all covered insulin pay $35 or less | 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 |
Optimum Emerald Partial (HMO D-SNP) - H5594-016-0
Benefit Details
|
Polk |
$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: $15.00 Preferred Brand: $45.00 Non-Preferred Drug: $95.00 Specialty Tier: 25%
all covered insulin pay $35 or less | n/a Browse Formulary |
|
|
|
|
Simply Complete (HMO D-SNP) - H5471-066-0
Benefit Details
|
Polk |
$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: $15.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $95.00 Specialty Tier: 25%
all covered insulin pay $35 or less | n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UnitedHealthcare Assisted Living Plan (PPO I-SNP) - H0710-012-0
Benefit Details
|
Polk |
$35.90 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | 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 Choice (PPO D-SNP) - H1889-002-1
Benefit Details
|
Polk |
$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%
all covered insulin pay $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Dual Complete LP (HMO-POS D-SNP) - H1045-039-0
Benefit Details
|
Polk |
$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%
all covered insulin pay $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Dual Complete ONE (HMO-POS D-SNP) - H2509-001-0
Benefit Details
|
Polk |
$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
all covered insulin pay $35 or less | n/a 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 |
UnitedHealthcare Dual Complete RP (Regional PPO D-SNP) - R0759-003-0
Benefit Details
|
Polk |
$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%
all covered insulin pay $35 or less | n/a Browse Formulary |
|
|
|
|
UnitedHealthcare Nursing Home Plan (PPO I-SNP) - H0710-010-0
Benefit Details
|
Polk |
$35.90 |
$505 |
No additional gap coverage, only the Donut Hole Discount | Tier 1: 25%
all covered insulin pay $35 or less | n/a Browse Formulary |
|
-- |
|
|
Wellcare Dual Access (HMO D-SNP) - H1032-124-0
Benefit Details
|
Polk |
$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
all covered insulin pay $35 or less | 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 |
Wellcare Dual Liberty (HMO D-SNP) - H1032-175-0
Benefit Details
|
Polk |
$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
all covered insulin pay $35 or less | n/a Browse Formulary |
|
|
|
|
BlueMedicare Choice (Regional PPO) - R3332-001-0
Benefit Details
|
Polk |
$49.90 |
$250 Tier 1, 2 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $93.00 Specialty Tier: 29% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,500 Browse Formulary |
|
|
|
|
Wellcare Premium Enhanced Open (PPO) - H5199-010-0
Benefit Details
|
Polk |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,500 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 R5826-005 (Regional PPO) - R5826-005-0
Benefit Details
|
Polk |
$111.00 |
$100 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $5.00 Generic: $15.00 Preferred Brand: $45.00 Non-Preferred Drug: $95.00 Specialty Tier: 31%
all covered insulin pay $35 or less | $6,700 Browse Formulary |
|
|
|
|