MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Ashland |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Brown |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Butler |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 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 |
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Carroll |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Clark |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Clermont |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 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 |
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Columbiana |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Cuyahoga |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Delaware |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 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 |
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Fairfield |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Franklin |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Fulton |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 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 |
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Geauga |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Greene |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Hamilton |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 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 |
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Hancock |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Hocking |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Holmes |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 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 |
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Lake |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Licking |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Lorain |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 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 |
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Lucas |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Madison |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Mahoning |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 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 |
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Marion |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Medina |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Miami |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 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 |
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Montgomery |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Morgan |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Morrow |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 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 |
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Muskingum |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Perry |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Pickaway |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 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 |
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Portage |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Seneca |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Stark |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 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 |
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Summit |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Trumbull |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Tuscarawas |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 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 |
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Union |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Warren |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Wayne |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 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 |
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Wood |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-1
Benefit Details
|
Wyandot |
$38.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Adams |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 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 |
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Allen |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Auglaize |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Champaign |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 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 |
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Clinton |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Coshocton |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Crawford |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 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 |
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Darke |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Defiance |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Erie |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 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 |
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Fayette |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Gallia |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Guernsey |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 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 |
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Hardin |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Harrison |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Henry |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 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 |
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Highland |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Huron |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Jackson |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 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 |
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Knox |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Lawrence |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Logan |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 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 |
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Mercer |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Monroe |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Noble |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 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 |
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Ottawa |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Paulding |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Pike |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 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 |
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Preble |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Putnam |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Richland |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 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 |
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Ross |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Sandusky |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Scioto |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 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 |
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Shelby |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Van Wert |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Vinton |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 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 |
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Washington |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
MedMutual Advantage Select (PPO) in OH - H4497-001-2
Benefit Details
|
Williams |
$98.00 |
$95 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Drug: 50% Specialty Tier: 31%
| $6,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|