Vantage PREMIUM (HMO-POS) in LA - H5576-018-1
Benefit Details
|
Allen |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-1
Benefit Details
|
Avoyelles |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-1
Benefit Details
|
Bossier |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 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 PREMIUM (HMO-POS) in LA - H5576-018-1
Benefit Details
|
Caddo |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-1
Benefit Details
|
Calcasieu |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-1
Benefit Details
|
Catahoula |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 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 PREMIUM (HMO-POS) in LA - H5576-018-1
Benefit Details
|
De Soto |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-1
Benefit Details
|
East Baton Rouge |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-1
Benefit Details
|
East Carroll |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 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 PREMIUM (HMO-POS) in LA - H5576-018-1
Benefit Details
|
Evangeline |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-1
Benefit Details
|
Franklin |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-1
Benefit Details
|
Jefferson |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 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 PREMIUM (HMO-POS) in LA - H5576-018-1
Benefit Details
|
LaSalle |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-1
Benefit Details
|
Lincoln |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-1
Benefit Details
|
Morehouse |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 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 PREMIUM (HMO-POS) in LA - H5576-018-1
Benefit Details
|
Ouachita |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-1
Benefit Details
|
Rapides |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-1
Benefit Details
|
Richland |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 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 PREMIUM (HMO-POS) in LA - H5576-018-1
Benefit Details
|
Sabine |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-1
Benefit Details
|
St. Helena |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-1
Benefit Details
|
St. Landry |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 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 PREMIUM (HMO-POS) in LA - H5576-018-1
Benefit Details
|
Tangipahoa |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-1
Benefit Details
|
Tensas |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-1
Benefit Details
|
Terrebonne |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 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 PREMIUM (HMO-POS) in LA - H5576-018-1
Benefit Details
|
Vernon |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-1
Benefit Details
|
Webster |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-1
Benefit Details
|
West Carroll |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 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 PREMIUM (HMO-POS) in LA - H5576-018-1
Benefit Details
|
Winn |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
Acadia |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
Ascension |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 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 PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
Assumption |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
Beauregard |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
Bienville |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 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 PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
Caldwell |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
Cameron |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
Claiborne |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 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 PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
Concordia |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
East Feliciana |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
Grant |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 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 PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
Iberia |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
Iberville |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
Jackson |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 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 PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
Jefferson Davis |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
Lafayette |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
Lafourche |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 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 PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
Livingston |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
Madison |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
Natchitoches |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 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 PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
Orleans |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
Plaquemines |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
Pointe Coupee |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 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 PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
Red River |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
St. Bernard |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
St. Charles |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 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 PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
St. James |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
St. John the Baptist |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
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|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
St. Martin |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 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 PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
St. Mary |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
St. Tammany |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
Union |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 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 PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
Vermilion |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
Washington |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
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|
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Higher cost-sharing at standard network pharmacies. Details:
|
Vantage PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
West Baton Rouge |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 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 PREMIUM (HMO-POS) in LA - H5576-018-2
Benefit Details
|
West Feliciana |
$171.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $14.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33%
select insulin pay $35 copay | $3,500 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|