Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Archer |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Austin |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Bailey |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a 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 |
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Briscoe |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Castro |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Chambers |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a 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 |
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Clay |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Cochran |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Collin |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a 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 |
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Colorado |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Cooke |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Crosby |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a 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 |
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Dallas |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Delta |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Denton |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a 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 |
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Dickens |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Floyd |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Fort Bend |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a 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 |
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Galveston |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Garza |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Grayson |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a 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 |
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Grimes |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Hale |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Hardin |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a 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 |
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Harris |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Henderson |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Hockley |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a 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 |
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Hunt |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Jack |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Jasper |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a 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 |
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Jefferson |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Johnson |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Lamb |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a 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 |
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Liberty |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Lubbock |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Lynn |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a 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 |
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Matagorda |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Montague |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Montgomery |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a 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 |
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Motley |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Navarro |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Orange |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a 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 |
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Palo Pinto |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Parker |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Rains |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a 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 |
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Rockwall |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
San Jacinto |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Swisher |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a 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 |
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Tarrant |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Terry |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Throckmorton |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a 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 |
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Van Zandt |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Walker |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Waller |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a 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 |
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Wharton |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Amerivantage ESRD Care Plus (HMO C-SNP) in TX - H2593-043-0
Benefit Details
|
Wise |
$0.00 |
$0 |
Few Generics | Preferred Generic: $5.00 Generic: $12.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|