Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Adjuntas |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Aguada |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Aguadilla |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $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 |
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Aguas Buenas |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Aibonito |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Anasco |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $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 |
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Arecibo |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Arroyo |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Barceloneta |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $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 |
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Barranquitas |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Bayamon |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Cabo Rojo |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $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 |
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Caguas |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Camuy |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Canovanas |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $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 |
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Carolina |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Catano |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Cayey |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $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 |
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Ceiba |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Ciales |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Cidra |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $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 |
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Coamo |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Comerio |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Corozal |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $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 |
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Culebra |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Dorado |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Fajardo |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $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 |
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Florida |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Guanica |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Guayama |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $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 |
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Guayanilla |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Guaynabo |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Gurabo |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $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 |
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Hatillo |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Hormigueros |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Humacao |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $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 |
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Isabela |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Jayuya |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Juana Diaz |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $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 |
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Juncos |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Lajas |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Lares |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $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 |
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Las Marias |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Las Piedras |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Loiza |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $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 |
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Luquillo |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Manati |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Maricao |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $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 |
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Maunabo |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Mayaguez |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Moca |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $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 |
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Morovis |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Naguabo |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Naranjito |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $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 |
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Orocovis |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Patillas |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Penuelas |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $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 |
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Ponce |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Quebradillas |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Rincon |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $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 |
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Rio Grande |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Sabana Grande |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Salinas |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $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 |
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
San German |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
San Juan |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
San Lorenzo |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $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 |
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
San Sebastian |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Santa Isabel |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Toa Alta |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $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 |
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Toa Baja |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Trujillo Alto |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Utuado |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $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 |
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Vega Alta |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Vega Baja |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Vieques |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $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 |
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Villalba |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Yabucoa |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Optimo Plus (PPO) in PR - H4005-004-0
Benefit Details
|
Yauco |
$99.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $25.00 Non-Preferred Brand: $40.00 Specialty Tier: 33% Select Care Drugs: $0.00
select insulin pay $3 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|