AhorroMax (HMO) - H5774-037-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $35.00 Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,650 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
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Basic (HMO) - H5774-003-0
Benefit Details
|
Sabana Grande |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,650 |
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Brillante (HMO-POS) - H5774-031-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $10.00 Non-Preferred Brand: $20.00 Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,650 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 |
Contigo Plus (HMO C-SNP) - H5774-022-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $0.00 Non-Preferred Brand: $10.00 Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Enlace Plus (HMO) - H5774-038-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $10.00 Non-Preferred Brand: $15.00 Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,650 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Gold Plus H4007-012 (HMO) - H4007-012-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $0.00 Non-Preferred Drug: $10.00 Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $5,000 Browse Formulary |
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|
Plan Name |
County |
Monthly Prem. |
Deduct- ible | Additional Gap Coverage | Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Humana Gold Plus H4007-020 (HMO) - H4007-020-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $0.00 Non-Preferred Drug: $15.00 Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $5,000 Browse Formulary |
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Humana Gold Plus H4007-021 (HMO) - H4007-021-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $0.00 Non-Preferred Drug: $15.00 Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $5,000 Browse Formulary |
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Humana Gold Plus H4007-024 (HMO) - H4007-024-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $0.00 Non-Preferred Drug: $0.00 Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $5,000 Browse Formulary |
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|
Plan Name |
County |
Monthly Prem. |
Deduct- ible | Additional Gap Coverage | Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Humana Gold Plus H4007-025 (HMO) - H4007-025-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $0.00 Non-Preferred Drug: $0.00 Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $5,000 Browse Formulary |
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Humana Gold Plus SNP-DE H4007-016 (HMO D-SNP) - H4007-016-0
Benefit Details
|
Sabana Grande |
$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 |
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Humana Gold Plus SNP-DE H4007-018 (HMO D-SNP) - H4007-018-0
Benefit Details
|
Sabana Grande |
$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 |
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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 |
Humana Gold Plus SNP-DE H4007-019 (HMO D-SNP) - H4007-019-0
Benefit Details
|
Sabana Grande |
$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 |
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Humana Gold Plus SNP-DE H4007-022 (HMO D-SNP) - H4007-022-0
Benefit Details
|
Sabana Grande |
$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 |
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Humana Gold Plus SNP-DE H4007-026 (HMO D-SNP) - H4007-026-0
Benefit Details
|
Sabana Grande |
$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 |
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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 |
Humana Gold Plus SNP-DE H4007-027 (HMO D-SNP) - H4007-027-0
Benefit Details
|
Sabana Grande |
$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 |
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Magno (HMO-POS) - H5774-027-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $5.00 Non-Preferred Brand: $25.00 Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,650 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
MCS Classicare Acceso (HMO-POS) - H5577-050-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $5.00 Non-Preferred Brand: $10.00 Specialty Tier: 33% Select Diabetic Drugs: $0.00
all covered insulin pay $35 or less | $3,400 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 |
MCS Classicare Activo (HMO) - H5577-031-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $5.00 Non-Preferred Brand: $15.00 Specialty Tier: 33% Select Diabetic Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
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MCS Classicare CeroCeroCero (HMO C-SNP) - H5577-045-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $0.00 Non-Preferred Brand: $0.00 Specialty Tier: 33% Select Diabetic Drugs: $0.00
all covered insulin pay $35 or less | n/a Browse Formulary |
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MCS Classicare Efectivo (HMO) - H5577-005-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $4.00 Non-Preferred Brand: $14.00 Specialty Tier: 33% Select Diabetic Drugs: $0.00
all covered insulin pay $35 or less | $3,400 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 |
MCS Classicare Electrico (HMO) - H5577-049-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $5.00 Non-Preferred Brand: $15.00 Specialty Tier: 33% Select Diabetic Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
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MCS Classicare En Tu Casa (HMO) - H5577-047-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $5.00 Non-Preferred Brand: $15.00 Specialty Tier: 33% Select Diabetic Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
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MCS Classicare En Tu Hogar (HMO) - H5577-043-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $5.00 Non-Preferred Brand: $15.00 Specialty Tier: 33% Select Diabetic Drugs: $0.00
all covered insulin pay $35 or less | $3,400 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 |
MCS Classicare Essential (HMO-POS) - H5577-008-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $0.00 Non-Preferred Brand: $0.00 Specialty Tier: 33% Select Diabetic Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
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MCS Classicare Exacto (HMO) - H5577-053-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $0.00 Non-Preferred Brand: $0.00 Specialty Tier: 33% Select Diabetic Drugs: $0.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
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MCS Classicare Firme (HMO) - H5577-042-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $0.00 Non-Preferred Brand: $0.00 Specialty Tier: 33% Select Diabetic Drugs: $0.00
all covered insulin pay $35 or less | $3,400 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 |
MCS Classicare Freedom (HMO) - H5577-014-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $3.00 Preferred Brand: $10.00 Non-Preferred Brand: $16.00 Specialty Tier: 33% Select Diabetic Drugs: $2.00
all covered insulin pay $35 or less | $6,700 Browse Formulary |
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MCS Classicare Hero (HMO) - H5577-044-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $30.00 Non-Preferred Brand: 25% Specialty Tier: 33% Select Diabetic Drugs: $5.00
all covered insulin pay $35 or less | $3,400 Browse Formulary |
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MCS Classicare InteliCare (HMO) - H5577-052-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $0.00 Non-Preferred Brand: $0.00 Specialty Tier: 33% Select Diabetic Drugs: $0.00
all covered insulin pay $35 or less | $3,400 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 |
MCS Classicare Patriot (HMO) - H5577-016-0
Benefit Details
|
Sabana Grande |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,400 |
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MCS Classicare Platino @Home (HMO D-SNP) - H5577-037-0
Benefit Details
|
Sabana Grande |
$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 |
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MCS Classicare Platino Ideal (HMO D-SNP) - H5577-002-0
Benefit Details
|
Sabana Grande |
$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 $35 or less | n/a Browse Formulary |
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|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible | Additional Gap Coverage | Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
MCS Classicare Platino MasCa$h (HMO D-SNP) - H5577-029-0
Benefit Details
|
Sabana Grande |
$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 |
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MCS Classicare Platino Progreso (HMO D-SNP) - H5577-017-0
Benefit Details
|
Sabana Grande |
$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 |
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MCS Classicare Platino Solido (HMO D-SNP) - H5577-041-0
Benefit Details
|
Sabana Grande |
$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 |
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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 |
MCS Classicare Platino Total (HMO D-SNP) - H5577-046-0
Benefit Details
|
Sabana Grande |
$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 |
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MCS Classicare Primero (HMO C-SNP) - H5577-038-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $0.00 Non-Preferred Brand: $0.00 Specialty Tier: 33% Select Diabetic Drugs: $0.00
all covered insulin pay $35 or less | n/a Browse Formulary |
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MCS Classicare SuperRx (HMO) - H5577-039-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $15.00 Non-Preferred Brand: $30.00 Specialty Tier: 33% Select Diabetic Drugs: $0.00
all covered insulin pay $35 or less | $3,400 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 |
MMM Balance (HMO-POS) - H4004-063-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $3.00 Non-Preferred Brand: $7.00 Specialty Tier: 25% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,250 Browse Formulary |
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MMM Deluxe (HMO-POS) - H4003-055-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $5.00 Non-Preferred Brand: $10.00 Specialty Tier: 25% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,250 Browse Formulary |
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MMM Diamante Platino (HMO D-SNP) - H4003-017-0
Benefit Details
|
Sabana Grande |
$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 |
|
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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 |
MMM Dinamico (HMO-POS) - H4003-051-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $5.00 Non-Preferred Brand: $16.00 Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,250 Browse Formulary |
|
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MMM Elite (HMO-POS) - H4003-034-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $0.00 Non-Preferred Brand: $0.00 Specialty Tier: 25% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,250 Browse Formulary |
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MMM Flexi Max (HMO-POS) - H4003-057-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $5.00 Non-Preferred Brand: $10.00 Specialty Tier: 25% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,250 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 |
MMM Grande Platino (HMO D-SNP) - H4003-049-0
Benefit Details
|
Sabana Grande |
$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 |
|
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|
|
MMM Integral (HMO C-SNP) - H4003-052-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $10.00 Non-Preferred Brand: $25.00 Specialty Tier: 25% Select Care Drugs: $0.00
all covered insulin pay $35 or less | n/a Browse Formulary |
|
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|
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MMM Plenitud (HMO-POS) - H4004-065-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $0.00 Non-Preferred Brand: $0.00 Specialty Tier: 25% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,250 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 |
MMM Relax Platino (HMO D-SNP) - H4004-062-0
Benefit Details
|
Sabana Grande |
$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 |
|
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|
|
MMM Supremo (HMO C-SNP) - H4003-009-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $0.00 Non-Preferred Brand: $20.00 Specialty Tier: 25% Select Care Drugs: $0.00
all covered insulin pay $35 or less | n/a Browse Formulary |
|
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MMM Valor Platino (HMO D-SNP) - H4003-047-0
Benefit Details
|
Sabana Grande |
$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 |
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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 |
Optimo (PPO) - H4005-001-0
Benefit Details
|
Sabana Grande |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $6,700 |
-- |
|
|
|
Optimo Plus (PPO) - H4005-004-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,700 Browse Formulary |
-- |
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platino Advance (HMO D-SNP) - H5774-026-0
Benefit Details
|
Sabana Grande |
$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: $10.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Brand: $95.00 Specialty Tier: 25% Select Care Drugs: $4.00
all covered insulin pay $35 or less | n/a 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 |
Platino Alcance (HMO D-SNP) - H5774-035-0
Benefit Details
|
Sabana Grande |
$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: $14.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Brand: $95.00 Specialty Tier: 25% Select Care Drugs: $7.00
all covered insulin pay $35 or less | n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Platino Blindao (HMO D-SNP) - H5774-028-0
Benefit Details
|
Sabana Grande |
$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: $10.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Brand: $95.00 Specialty Tier: 25% Select Care Drugs: $10.00
all covered insulin pay $35 or less | n/a Browse Formulary |
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|
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Higher cost-sharing at standard network pharmacies. Details:
|
Platino Plus (HMO D-SNP) - H5774-024-0
Benefit Details
|
Sabana Grande |
$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: $14.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Brand: $95.00 Specialty Tier: 25% Select Care Drugs: $8.00
all covered insulin pay $35 or less | n/a 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 |
Platino Titan (HMO D-SNP) - H5774-036-0
Benefit Details
|
Sabana Grande |
$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: $14.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Brand: $95.00 Specialty Tier: 25% Select Care Drugs: $8.00
all covered insulin pay $35 or less | n/a Browse Formulary |
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|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Platino Ultra (HMO D-SNP) - H5774-025-0
Benefit Details
|
Sabana Grande |
$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: $14.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Brand: $95.00 Specialty Tier: 25% Select Care Drugs: $10.00
all covered insulin pay $35 or less | n/a Browse Formulary |
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|
|
Higher cost-sharing at standard network pharmacies. Details:
|
PMC Max (HMO-POS) - H4004-056-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $5.00 Non-Preferred Brand: $10.00 Specialty Tier: 25% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,250 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 |
PMC Premier Platino (HMO D-SNP) - H4004-048-0
Benefit Details
|
Sabana Grande |
$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 |
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|
|
|
Real (HMO) - H5774-005-0
Benefit Details
|
Sabana Grande |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $0.00 Non-Preferred Brand: $5.00 Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,650 Browse Formulary |
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|
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Higher cost-sharing at standard network pharmacies. Details:
|
MMM Unico (HMO-POS) - H4003-019-0
Benefit Details
|
Sabana Grande |
$15.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $0.00 Non-Preferred Brand: $0.00 Specialty Tier: 25% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $3,250 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 |
HumanaChoice Value H2029-001 (PPO) - H2029-001-0
Benefit Details
|
Sabana Grande |
$38.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Drug: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,700 Browse Formulary |
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Optimo Xtra (PPO) - H4005-007-0
Benefit Details
|
Sabana Grande |
$40.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $15.00 Non-Preferred Brand: $30.00 Specialty Tier: 33% Select Care Drugs: $0.00
all covered insulin pay $35 or less | $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|