Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Barrow |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Bartow |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Bibb |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 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 GA - H5422-013-0
Benefit Details
|
Bryan |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Bulloch |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Burke |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 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 GA - H5422-013-0
Benefit Details
|
Butts |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Chatham |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Chattahoochee |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 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 GA - H5422-013-0
Benefit Details
|
Cherokee |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Clayton |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Cobb |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 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 GA - H5422-013-0
Benefit Details
|
Coffee |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Columbia |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Coweta |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 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 GA - H5422-013-0
Benefit Details
|
Crawford |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Crisp |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
DeKalb |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 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 GA - H5422-013-0
Benefit Details
|
Dodge |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Douglas |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Effingham |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 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 GA - H5422-013-0
Benefit Details
|
Fayette |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Forsyth |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Fulton |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 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 GA - H5422-013-0
Benefit Details
|
Gilmer |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Glascock |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Greene |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 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 GA - H5422-013-0
Benefit Details
|
Gwinnett |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Harris |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Heard |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 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 GA - H5422-013-0
Benefit Details
|
Henry |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Houston |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Jasper |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 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 GA - H5422-013-0
Benefit Details
|
Jefferson |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Jones |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Lamar |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 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 GA - H5422-013-0
Benefit Details
|
Laurens |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Liberty |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
McDuffie |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 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 GA - H5422-013-0
Benefit Details
|
Macon |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Marion |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Meriwether |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 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 GA - H5422-013-0
Benefit Details
|
Monroe |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Muscogee |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Newton |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 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 GA - H5422-013-0
Benefit Details
|
Paulding |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Peach |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Pickens |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 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 GA - H5422-013-0
Benefit Details
|
Pike |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Richmond |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Rockdale |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 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 GA - H5422-013-0
Benefit Details
|
Spalding |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Talbot |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Taylor |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 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 GA - H5422-013-0
Benefit Details
|
Tift |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Toombs |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Troup |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 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 GA - H5422-013-0
Benefit Details
|
Twiggs |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Walton |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Anthem MediBlue Extra (HMO) in GA - H5422-013-0
Benefit Details
|
Warren |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 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 GA - H5422-013-0
Benefit Details
|
White |
$29.80 |
$445 Tier 1 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $95.00 Specialty Tier: 25% Select Care Drugs: $0.00
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|