Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Adams |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Allen |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Bartholomew |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Benton |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Blackford |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Boone |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Brown |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Carroll |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Cass |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Clark |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Clay |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Clinton |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Crawford |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Daviess |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Dearborn |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Decatur |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
De Kalb |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Delaware |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Dubois |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Elkhart |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Fayette |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Floyd |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Fountain |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Franklin |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Fulton |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Gibson |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Grant |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Greene |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Hamilton |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Hancock |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Harrison |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Hendricks |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Henry |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Howard |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Huntington |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Jackson |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Jasper |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Jay |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Jefferson |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Jennings |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Johnson |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Knox |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Kosciusko |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Lagrange |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Lake |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
La Porte |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Lawrence |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Madison |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Marion |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Marshall |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Martin |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Miami |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Monroe |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Montgomery |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Morgan |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Newton |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Noble |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Ohio |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Orange |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Owen |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Parke |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Perry |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Pike |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Porter |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Posey |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Pulaski |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Putnam |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Randolph |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Ripley |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Rush |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
St. Joseph |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Scott |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Shelby |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Spencer |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Starke |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Steuben |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Sullivan |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Switzerland |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Tippecanoe |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Tipton |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Union |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Vanderburgh |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Vermillion |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Vigo |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Wabash |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Warren |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Warrick |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Washington |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Wayne |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Wells |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 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 Extra (HMO) in IN - H3447-024-0
Benefit Details
|
White |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in IN - H3447-024-0
Benefit Details
|
Whitley |
$29.60 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $9.00 Preferred Brand: $37.00 Non-Preferred Drug: $90.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|