Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Appling |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Atkinson |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Bacon |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $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 |
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Baldwin |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Ben Hill |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Bleckley |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $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 |
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Butts |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Candler |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Clayton |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $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 |
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Clinch |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Coffee |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Crawford |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $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 |
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Dawson |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
DeKalb |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Dodge |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $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 |
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Dooly |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Douglas |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Emanuel |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $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 |
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Evans |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Forsyth |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Fulton |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $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 |
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Heard |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Houston |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Irwin |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $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 |
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Jasper |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Jeff Davis |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Jenkins |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $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 |
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Johnson |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Jones |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Lamar |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $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 |
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Long |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
McIntosh |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Macon |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $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 |
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Meriwether |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Monroe |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Montgomery |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $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 |
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Peach |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Pickens |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Pike |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $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 |
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Polk |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Pulaski |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Screven |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $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 |
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Tattnall |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Taylor |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Telfair |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $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 |
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Treutlen |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Turner |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Twiggs |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $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 |
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Upson |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Ware |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Washington |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $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 |
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Wayne |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Wheeler |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Wilcox |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $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 |
Clover Health Choice (PPO) in GA - H5141-046-0
Benefit Details
|
Wilkinson |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $40.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|