Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Allen |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Bartholomew |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Benton |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 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 |
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Blackford |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Boone |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Brown |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 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 |
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Carroll |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Cass |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Clark |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 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 |
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Clay |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Clinton |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Daviess |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 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 |
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Dearborn |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Decatur |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
De Kalb |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 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 |
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Delaware |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Dubois |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Elkhart |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 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 |
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Fayette |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Floyd |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Fountain |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 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 |
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Franklin |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Gibson |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Grant |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 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 |
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Greene |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Hamilton |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Hancock |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 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 |
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Harrison |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Hendricks |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Howard |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 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 |
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Huntington |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Jackson |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Jay |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 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 |
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Jefferson |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Jennings |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Johnson |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 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 |
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Knox |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Kosciusko |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Lagrange |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 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 |
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Lake |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
La Porte |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Madison |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 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 |
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Marion |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Martin |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Monroe |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 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 |
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Morgan |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Newton |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Noble |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 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 |
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Ohio |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Parke |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Perry |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 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 |
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Pike |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Porter |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Posey |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 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 |
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Putnam |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Randolph |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
St. Joseph |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 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 |
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Scott |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Shelby |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Spencer |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 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 |
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Switzerland |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Tippecanoe |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Tipton |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 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 |
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Union |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Vanderburgh |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Vermillion |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 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 |
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Vigo |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Wabash |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Warren |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 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 |
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Warrick |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Washington |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Wayne |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 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 |
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Wells |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
White |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Access Plus (PPO) in IN - H1607-012-0
Benefit Details
|
Whitley |
$54.00 |
$60 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 32% Select Care Drugs: $0.00
| $6,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|