CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Adams |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Allen |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Benton |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 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 |
CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Blackford |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Boone |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Brown |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 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 |
CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Carroll |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Cass |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Clark |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 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 |
CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Clay |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Clinton |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Crawford |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 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 |
CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Decatur |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
De Kalb |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Delaware |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 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 |
CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Fayette |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Floyd |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Fountain |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 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 |
CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Greene |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Hamilton |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Hancock |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 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 |
CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Harrison |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Hendricks |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Henry |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 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 |
CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Huntington |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Jackson |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Jay |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 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 |
CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Jennings |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Johnson |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Lawrence |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 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 |
CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Madison |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Marion |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Martin |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 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 |
CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Miami |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Monroe |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Montgomery |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 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 |
CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Morgan |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Orange |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Owen |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 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 |
CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Parke |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Pulaski |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Putnam |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 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 |
CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Randolph |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Rush |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Scott |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 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 |
CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Shelby |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
|
CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Starke |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
|
CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Sullivan |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 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 |
CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Tippecanoe |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
|
CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Tipton |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
new |
|
CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Union |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 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 |
CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Wabash |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
new |
new |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Warren |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Washington |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 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 |
CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Wells |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
White |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
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CareSource Advantage Zero Premium (HMO) in IN - H9162-004-0
Benefit Details
|
Whitley |
$0.00 |
$250 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
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