AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-1
Benefit Details
|
De Soto |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-1
Benefit Details
|
East Baton Rouge |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-1
Benefit Details
|
East Carroll |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-1
Benefit Details
|
Franklin |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-1
Benefit Details
|
Morehouse |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-1
Benefit Details
|
Ouachita |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-1
Benefit Details
|
Richland |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-1
Benefit Details
|
St. Helena |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-1
Benefit Details
|
Tangipahoa |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-1
Benefit Details
|
West Carroll |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Acadia |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Allen |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Ascension |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Assumption |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Avoyelles |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Beauregard |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Bienville |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Bossier |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Caddo |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Calcasieu |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Caldwell |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Cameron |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Catahoula |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Claiborne |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Concordia |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
East Feliciana |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Evangeline |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Grant |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Iberia |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Iberville |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Jackson |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Jefferson |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Jefferson Davis |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Lafayette |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Lafourche |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
LaSalle |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Lincoln |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Livingston |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Madison |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Natchitoches |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Orleans |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Plaquemines |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Pointe Coupee |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Rapides |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Red River |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Sabine |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
St. Bernard |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
St. Charles |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
St. James |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
St. John the Baptist |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
St. Landry |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
St. Martin |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
St. Mary |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
St. Tammany |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Tensas |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Terrebonne |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Union |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Vermilion |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Vernon |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Washington |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Webster |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
West Baton Rouge |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
West Feliciana |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
AAA8 Vantage BASIC (HMO-POS) in LA - H5576-020-2
Benefit Details
|
Winn |
$0.00 |
$310 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $15.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
|