Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Arkansas |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Ashley |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Benton |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $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 |
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Bradley |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Calhoun |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Carroll |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $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 |
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Chicot |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Clark |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Clay |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $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 |
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Cleburne |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Cleveland |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Columbia |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $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 |
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Conway |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Craighead |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Cross |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $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 |
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Dallas |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Desha |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Drew |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $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 |
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Franklin |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Garland |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Grant |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $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 |
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Greene |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Hot Spring |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Independence |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $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 |
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Jackson |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Jefferson |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Johnson |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $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 |
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Lafayette |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Lawrence |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Lee |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $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 |
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Lincoln |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Logan |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Lonoke |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $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 |
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Madison |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Mississippi |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Monroe |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $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 |
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Montgomery |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Nevada |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Newton |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $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 |
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Ouachita |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Perry |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Phillips |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $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 |
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Pike |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Poinsett |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Polk |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $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 |
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Pope |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Prairie |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Pulaski |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $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 |
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Randolph |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
St. Francis |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Saline |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $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 |
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Scott |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Stone |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Union |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $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 |
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Van Buren |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Washington |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
White |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $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 |
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Woodruff |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vantage Giveback (HMO-POS) in AR - H2722-005-0
Benefit Details
|
Yell |
$0.00 |
$505 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $5,900 Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|