UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Allegheny |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Armstrong |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Beaver |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| 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 |
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Bedford |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Berks |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Blair |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| 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 |
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Bradford |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Bucks |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Butler |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| 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 |
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Cambria |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Cameron |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Chester |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| 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 |
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Clarion |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Clearfield |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Clinton |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| 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 |
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Crawford |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Cumberland |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Dauphin |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| 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 |
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Delaware |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Elk |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Erie |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| 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 |
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Fayette |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Forest |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Fulton |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| 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 |
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Greene |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Huntingdon |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Indiana |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| 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 |
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Jefferson |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Juniata |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Lackawanna |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| 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 |
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Lancaster |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Lawrence |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Lebanon |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| 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 |
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Lehigh |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Luzerne |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Lycoming |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| 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 |
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
McKean |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Mercer |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Mifflin |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| 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 |
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Montgomery |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Northampton |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Perry |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| 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 |
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Philadelphia |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Potter |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Snyder |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| 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 |
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Somerset |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
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UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Sullivan |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Susquehanna |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| 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 |
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Tioga |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Union |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Venango |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| 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 |
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Warren |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Washington |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Wayne |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| 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 |
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Westmoreland |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
Wyoming |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life Dual (HMO SNP) in PA - H4279-001-0
Benefit Details
|
York |
$0.00 for people who qualify for both Medicare and Medicaid. |
$0 for people who qualify for both Medicare and Medicaid. |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $6.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|