Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Adams |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Allen |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Ashland |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% 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 |
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Ashtabula |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Athens |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Auglaize |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% 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 |
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Belmont |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Brown |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Butler |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% 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 |
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Carroll |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Champaign |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Clark |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% 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 |
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Clermont |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Clinton |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Columbiana |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% 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 |
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Coshocton |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Crawford |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Cuyahoga |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% 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 |
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Darke |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Defiance |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Delaware |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% 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 |
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Erie |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Fairfield |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Fayette |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% 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 |
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Franklin |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Fulton |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Gallia |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% 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 |
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Geauga |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Greene |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Guernsey |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% 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 |
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Hamilton |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Hancock |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Hardin |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% 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 |
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Harrison |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Henry |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Highland |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% 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 |
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Hocking |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Holmes |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Huron |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% 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 |
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Jackson |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Jefferson |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Lake |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% 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 |
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Lawrence |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Licking |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Logan |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% 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 |
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Lorain |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Lucas |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Madison |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% 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 |
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Mahoning |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Marion |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Medina |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% 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 |
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Meigs |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Mercer |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Miami |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% 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 |
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Monroe |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Montgomery |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Morgan |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% 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 |
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Morrow |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Muskingum |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Noble |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% 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 |
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Ottawa |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Paulding |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Perry |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% 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 |
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Pickaway |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Pike |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Portage |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% 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 |
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Preble |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Putnam |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Richland |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% 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 |
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Ross |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Sandusky |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Scioto |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% 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 |
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Seneca |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Shelby |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Stark |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% 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 |
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Summit |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Trumbull |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Tuscarawas |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% 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 |
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Union |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Van Wert |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Vinton |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% 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 |
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Warren |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Washington |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Wayne |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% 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 |
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Williams |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Wood |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in OH - H3655-041-0
Benefit Details
|
Wyandot |
$32.90 |
$415 Tier 1 and 6 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|