AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Adams |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Allegheny |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Armstrong |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $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 |
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Beaver |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Bedford |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Berks |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $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 |
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Blair |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Bucks |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Butler |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $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 |
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Cambria |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Carbon |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Centre |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $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 |
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Chester |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Clearfield |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Clinton |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $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 |
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Columbia |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Cumberland |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Dauphin |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $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 |
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Delaware |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Fayette |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Franklin |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $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 |
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Fulton |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Greene |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Huntingdon |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $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 |
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Indiana |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Jefferson |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Juniata |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $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 |
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Lackawanna |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Lancaster |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Lawrence |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $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 |
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Lycoming |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
McKean |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Mifflin |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $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 |
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Monroe |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Montgomery |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Montour |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $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 |
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Northampton |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Northumberland |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Perry |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $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 |
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Philadelphia |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Potter |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Schuylkill |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $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 |
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Snyder |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Somerset |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Sullivan |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $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 |
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Susquehanna |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Union |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Warren |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $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 |
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Washington |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Wayne |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Westmoreland |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
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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 |
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
Wyoming |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
AdvantraOne (PPO) in PA - H5522-017-0
Benefit Details
|
York |
$19.00 |
$195 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|