Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Albemarle |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Amelia |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Amherst |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 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 |
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Appomattox |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Brunswick |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Buckingham |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 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 |
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Campbell |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Caroline |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Charlotte |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 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 |
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Chesterfield |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Cumberland |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Dinwiddie |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 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 |
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Essex |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Fluvanna |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Goochland |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 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 |
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Greensville |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Halifax |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Hanover |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 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 |
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Henrico |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
King and Queen |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
King George |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 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 |
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
King William |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Lancaster |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Louisa |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 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 |
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Lunenburg |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Mecklenburg |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Middlesex |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 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 |
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Nelson |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
New Kent |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Northumberland |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 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 |
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Nottoway |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Pittsylvania |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Powhatan |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 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 |
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Prince Edward |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Prince George |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Richmond |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 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 |
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Southampton |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Stafford |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Westmoreland |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 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 |
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Charlottesville City |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Colonial Heights City |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Danville City |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 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 |
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Emporia City |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Hopewell City |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Lynchburg City |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 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 |
Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
|
Petersburg City |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
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Sentara Medicare Value (HMO) in VA - H2563-009-0
Benefits & Contact Info
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Richmond City |
$0.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $42.00 Non-Preferred Drug: $95.00 Specialty Tier: 30%
all covered insulin pay $35 or less | $3,300 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
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