UPMC for Life HMO Rx Enhanced (HMO) in OH - H3907-006-0
Benefit Details
|
Harrison |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in OH - H3907-006-0
Benefit Details
|
Jefferson |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Adams |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 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 |
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Allegheny |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Armstrong |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Beaver |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 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 |
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Bedford |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Berks |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Blair |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 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 |
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Bradford |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Butler |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Cambria |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 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 |
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Cameron |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Carbon |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Centre |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 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 |
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Clarion |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Clearfield |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Clinton |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 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 |
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Crawford |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Cumberland |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Dauphin |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 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 |
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Elk |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Erie |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Fayette |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 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 |
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Forest |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Fulton |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Greene |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 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 |
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Huntingdon |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Indiana |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Jefferson |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 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 |
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Juniata |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Lancaster |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Lawrence |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 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 |
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Lebanon |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Lehigh |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Lycoming |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 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 |
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
McKean |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Mercer |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Mifflin |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 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 |
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Montour |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Northampton |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Perry |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 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 |
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Potter |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Snyder |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Somerset |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 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 |
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Sullivan |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Susquehanna |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Tioga |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 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 |
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Union |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Venango |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Warren |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 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 |
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Washington |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Wayne |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Westmoreland |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 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 |
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
Wyoming |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UPMC for Life HMO Rx Enhanced (HMO) in PA - H3907-006-0
Benefit Details
|
York |
$302.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|