Vantage STANDARD (HMO-POS) in LA - H5576-017-1
Benefit Details
|
Allen |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-1
Benefit Details
|
Avoyelles |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-1
Benefit Details
|
Bossier |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 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 |
Vantage STANDARD (HMO-POS) in LA - H5576-017-1
Benefit Details
|
Caddo |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-1
Benefit Details
|
Calcasieu |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-1
Benefit Details
|
Catahoula |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 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 |
Vantage STANDARD (HMO-POS) in LA - H5576-017-1
Benefit Details
|
De Soto |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-1
Benefit Details
|
East Baton Rouge |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-1
Benefit Details
|
East Carroll |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 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 |
Vantage STANDARD (HMO-POS) in LA - H5576-017-1
Benefit Details
|
Evangeline |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-1
Benefit Details
|
Franklin |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-1
Benefit Details
|
Jefferson |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 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 |
Vantage STANDARD (HMO-POS) in LA - H5576-017-1
Benefit Details
|
LaSalle |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-1
Benefit Details
|
Lincoln |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-1
Benefit Details
|
Morehouse |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 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 |
Vantage STANDARD (HMO-POS) in LA - H5576-017-1
Benefit Details
|
Ouachita |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-1
Benefit Details
|
Rapides |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-1
Benefit Details
|
Richland |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 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 |
Vantage STANDARD (HMO-POS) in LA - H5576-017-1
Benefit Details
|
Sabine |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-1
Benefit Details
|
St. Helena |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-1
Benefit Details
|
St. Landry |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 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 |
Vantage STANDARD (HMO-POS) in LA - H5576-017-1
Benefit Details
|
Tangipahoa |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-1
Benefit Details
|
Tensas |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-1
Benefit Details
|
Terrebonne |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 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 |
Vantage STANDARD (HMO-POS) in LA - H5576-017-1
Benefit Details
|
Vernon |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-1
Benefit Details
|
Webster |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-1
Benefit Details
|
West Carroll |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 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 |
Vantage STANDARD (HMO-POS) in LA - H5576-017-1
Benefit Details
|
Winn |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
Acadia |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
Ascension |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 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 |
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
Assumption |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
Beauregard |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
Bienville |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 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 |
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
Caldwell |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
Cameron |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
Claiborne |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 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 |
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
Concordia |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
East Feliciana |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
Grant |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 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 |
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
Iberia |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
Iberville |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
Jackson |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 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 |
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
Jefferson Davis |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
Lafayette |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
Lafourche |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 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 |
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
Livingston |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
Madison |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
Natchitoches |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 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 |
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
Orleans |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
Plaquemines |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
Pointe Coupee |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 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 |
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
Red River |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
St. Bernard |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
St. Charles |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 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 |
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
St. James |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
St. John the Baptist |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
St. Martin |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 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 |
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
St. Mary |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
St. Tammany |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
Union |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 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 |
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
Vermilion |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
Washington |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
West Baton Rouge |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 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 |
Vantage STANDARD (HMO-POS) in LA - H5576-017-2
Benefit Details
|
West Feliciana |
$36.40 |
$480 Tier 1, 2 and 3 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
select insulin pay $35 copay | $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|