Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Benton |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Cannon |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Cheatham |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $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 |
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Claiborne |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Clay |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Davidson |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $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 |
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Decatur |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
DeKalb |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Dickson |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $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 |
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Dyer |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Fayette |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Fentress |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $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 |
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Gibson |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Giles |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Hamilton |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $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 |
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Hardin |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Henry |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Hickman |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $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 |
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Houston |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Jackson |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Jefferson |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 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 |
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Knox |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Lawrence |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Lewis |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 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 |
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Lincoln |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Macon |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Marshall |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 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 |
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Maury |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
McNairy |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Meigs |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 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 |
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Montgomery |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Overton |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Perry |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $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 |
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Polk |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Robertson |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Rutherford |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $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 |
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Shelby |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Stewart |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Sumner |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $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 |
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Tipton |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Van Buren |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Warren |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $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 |
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Wayne |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
White |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Williamson |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $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 |
Amerivantage Classic (HMO) in TN - H7200-007-0
Benefit Details
|
Wilson |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Brand: $83.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|