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Drug Sponsor Name
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Sierra Health and Life Insurance Company, Inc.
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Drug Plan Name
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SierraRx Basic (S5917-010)
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Phone Number
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Current Members: 1-866-729-6929 TTY/TDD: 1-877-730-4203 Prospective Members: 1-866-819-3449 TTY/TDD: 1-877-730-4203
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Website
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www.sierrarx2009.com
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Total monthly premium
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$66.90
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SPDAP monthly subsidy
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Up to $25 per month
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Monthly premium after subsidy
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$41.90
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Deductible
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$295.00
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1st tier copay
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25%
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2nd tier copay
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25%
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3rd tier copay
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25%
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4th tier copay, and description (such as injectibles, if applicable)
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N/A
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Initial coverage limit [as defined in 42 CFR Part 423.104(d)(3)]
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$2,700.00
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Benefits available in coverage gap
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None
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Average drug price discount percentage below wholesale drug price available in coverage gap (for example, 95% equals a 5% price discount)
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N/A
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Mail order offered
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25% co-insurance for 90-day supply
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Does this plan option’s formulary differ from plan sponsor’s other options
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No
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Medical management requirements (UM, PA)
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Yes - Contact plan for details
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Maryland SPDAP Coverage Gap Subsidy
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Not offered in this plan option
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