Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Autauga |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
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Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Baldwin |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Barbour |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 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 |
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Bibb |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Blount |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Bullock |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 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 |
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Butler |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Calhoun |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Chambers |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 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 |
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Cherokee |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Chilton |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Choctaw |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 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 |
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Clarke |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Clay |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Cleburne |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 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 |
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Coffee |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Colbert |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Conecuh |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 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 |
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Coosa |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Covington |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Crenshaw |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 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 |
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Cullman |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Dale |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Dallas |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 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 |
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
DeKalb |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Elmore |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Escambia |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 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 |
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Etowah |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Fayette |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Franklin |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 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 |
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Geneva |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Greene |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Hale |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 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 |
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Henry |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Houston |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Jackson |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 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 |
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Jefferson |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Lamar |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Lauderdale |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 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 |
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Lawrence |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Lee |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Limestone |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 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 |
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Lowndes |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Macon |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Madison |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 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 |
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Marengo |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Marion |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Marshall |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 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 |
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Mobile |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Monroe |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Montgomery |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 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 |
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Morgan |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Perry |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Pickens |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 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 |
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Pike |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Randolph |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Russell |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 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 |
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
St. Clair |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Shelby |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Sumter |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 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 |
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Talladega |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Tallapoosa |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Tuscaloosa |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 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 |
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Walker |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Washington |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Wilcox |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 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 |
Blue Advantage Premier (PPO) in AL - H0104-015-0
Benefit Details
|
Winston |
$170.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Drug: 45% Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|