Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Adjuntas |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
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Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Aguada |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Aguadilla |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| 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 |
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Aguas Buenas |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Aibonito |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Anasco |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| 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 |
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Arecibo |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Arroyo |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
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Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Barceloneta |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| 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 |
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Barranquitas |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Bayamon |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Cabo Rojo |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| 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 |
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Caguas |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Camuy |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Canovanas |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| 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 |
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Carolina |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Catano |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Cayey |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| 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 |
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Ceiba |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Ciales |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Cidra |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| 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 |
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Coamo |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Comerio |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Corozal |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| 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 |
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Culebra |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Dorado |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Fajardo |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| 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 |
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Florida |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Guanica |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Guayama |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| 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 |
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Guayanilla |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Guaynabo |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Gurabo |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| 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 |
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Hatillo |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Hormigueros |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Humacao |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| 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 |
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Isabela |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Jayuya |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Juana Diaz |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| 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 |
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Juncos |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Lajas |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Lares |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| 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 |
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Las Marias |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Las Piedras |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Loiza |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| 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 |
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Luquillo |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Manati |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Maricao |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| 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 |
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Maunabo |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Mayaguez |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Moca |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| 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 |
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Morovis |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Naguabo |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Naranjito |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| 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 |
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Orocovis |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Patillas |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Penuelas |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| 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 |
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Ponce |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Quebradillas |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Rincon |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| 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 |
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Rio Grande |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Sabana Grande |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Salinas |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| 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 |
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
San German |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
San Juan |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
San Lorenzo |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| 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 |
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
San Sebastian |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Santa Isabel |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Toa Alta |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| 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 |
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Toa Baja |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Trujillo Alto |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Utuado |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| 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 |
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Vega Alta |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Vega Baja |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Vieques |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| 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 |
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Villalba |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Yabucoa |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Triple S Advantage Vital Plus (HMO SNP) in PR - H5774-022-0
Benefit Details
|
Yauco |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $5.00 Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $50.00 Specialty Tier: 33%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|