Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Barbour |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Berkeley |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Braxton |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 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 |
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Brooke |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Calhoun |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Doddridge |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 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 |
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Gilmer |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Grant |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Hampshire |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 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 |
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Hancock |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Hardy |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Harrison |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 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 |
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Jefferson |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Lewis |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Marion |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 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 |
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Marshall |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Mineral |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Monongalia |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 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 |
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Morgan |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Ohio |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Pendleton |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 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 |
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Pleasants |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Preston |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Randolph |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 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 |
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Ritchie |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Taylor |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Tucker |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 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 |
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Tyler |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Upshur |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Wetzel |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 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 |
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Wirt |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-1
Benefits & Contact Info
|
Wood |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-2
Benefits & Contact Info
|
Boone |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 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 |
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-2
Benefits & Contact Info
|
Cabell |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-2
Benefits & Contact Info
|
Clay |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-2
Benefits & Contact Info
|
Fayette |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 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 |
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-2
Benefits & Contact Info
|
Greenbrier |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-2
Benefits & Contact Info
|
Jackson |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-2
Benefits & Contact Info
|
Kanawha |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 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 |
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-2
Benefits & Contact Info
|
Lincoln |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-2
Benefits & Contact Info
|
Logan |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-2
Benefits & Contact Info
|
McDowell |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 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 |
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-2
Benefits & Contact Info
|
Mason |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-2
Benefits & Contact Info
|
Mercer |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-2
Benefits & Contact Info
|
Mingo |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 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 |
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-2
Benefits & Contact Info
|
Monroe |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-2
Benefits & Contact Info
|
Nicholas |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-2
Benefits & Contact Info
|
Pocahontas |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 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 |
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-2
Benefits & Contact Info
|
Putnam |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-2
Benefits & Contact Info
|
Raleigh |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-2
Benefits & Contact Info
|
Roane |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 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 |
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-2
Benefits & Contact Info
|
Summers |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-2
Benefits & Contact Info
|
Wayne |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-2
Benefits & Contact Info
|
Webster |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 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 |
Freedom Blue PPO Prestige (PPO) in WV - H5106-032-2
Benefits & Contact Info
|
Wyoming |
$39.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $42.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
all covered insulin pay $35 or less | $5,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|