Generated Narrative: InsurancePlan PayerInsurancePlanA3004t Last updated: 2021-08-04 18:36:03+0000 Profile: Payer Insurance Plan identifier: A3004t status: Active type: Medicare Advantage name: Sample Medicare Advantage Plan A3004t period: 2021-01-01 --> 2021-12-31 coverageArea: Location United States Area contact purpose: Patient telecom: +1 (888) 555-3004 contact purpose: Marketting name: Sample Medicare Advantage Plan Marketing Website telecom: http://url/to/health/plan/information contact purpose: Summary name: Sample Medicare Advantage Drug Plan Benefit Website telecom: http://url/to/health/plan/information contact purpose: Formulary name: Sample Medicare Advantage Drug Plan Formulary Website telecom: http://url/to/health/plan/information coverage Formulary Reference: InsurancePlan Sample Medicare Advantage Part D Formulary D3004t type: drug policy Benefits - Type * Drug plan type: Drug specificCost category: 1 month in network retail benefit type: Generic cost type: Copay qualifiers: No Charge value: 10 $ (Details: unknown codeUSD = 'United States dollar') cost type: Coinsurance qualifiers: After Deductible value: 0 % (Details: UCUM code% = '%') specificCost category: 1 month out of network retail benefit type: Generic cost type: Copay qualifiers: No Charge value: 10 $ (Details: unknown codeUSD = 'United States dollar') cost type: Coinsurance qualifiers: After Deductible value: 0 % (Details: UCUM code% = '%') specificCost category: 3 month in network retail benefit type: Generic cost type: Copay qualifiers: No Charge value: 20 $ (Details: unknown codeUSD = 'United States dollar') cost type: Coinsurance qualifiers: After Deductible value: 0 % (Details: UCUM code% = '%') specificCost category: 3 month out of network retail benefit type: Generic cost type: Copay qualifiers: No Charge value: 20 $ (Details: unknown codeUSD = 'United States dollar') cost type: Coinsurance qualifiers: After Deductible value: 0 % (Details: UCUM code% = '%') specificCost category: 1 month in network retail benefit type: Zero cost-share preventative cost type: Copay qualifiers: No Charge value: 0 $ (Details: unknown codeUSD = 'United States dollar') cost type: Coinsurance qualifiers: No Charge value: 0 % (Details: UCUM code% = '%') specificCost category: 1 month out of network retail benefit type: Zero cost-share preventative cost type: Copay qualifiers: No Charge value: 0 $ (Details: unknown codeUSD = 'United States dollar') cost type: Coinsurance qualifiers: No Charge value: 0 % (Details: UCUM code% = '%') specificCost category: 3 month in network retail benefit type: Zero cost-share preventative cost type: Copay qualifiers: No Charge value: 0 $ (Details: unknown codeUSD = 'United States dollar') cost type: Coinsurance qualifiers: No Charge value: 0 % (Details: UCUM code% = '%') specificCost category: 3 month out of network retail benefit type: Zero cost-share preventative cost type: Copay qualifiers: No Charge value: 0 $ (Details: unknown codeUSD = 'United States dollar') cost type: Coinsurance qualifiers: No Charge value: 0 % (Details: UCUM code% = '%') specificCost category: 1 month in network retail benefit type: Preferred Brand cost type: Copay qualifiers: No Charge value: 50 $ (Details: unknown codeUSD = 'United States dollar') cost type: Coinsurance qualifiers: After Deductible value: 0 % (Details: UCUM code% = '%') specificCost category: 1 month out of network retail benefit type: Preferred Brand cost type: Copay qualifiers: No Charge value: 50 $ (Details: unknown codeUSD = 'United States dollar') cost type: Coinsurance qualifiers: After Deductible value: 0 % (Details: UCUM code% = '%') specificCost category: 3 month in network retail benefit type: Preferred Brand cost type: Copay qualifiers: No Charge value: 100 $ (Details: unknown codeUSD = 'United States dollar') cost type: Coinsurance qualifiers: After Deductible value: 0 % (Details: UCUM code% = '%') specificCost category: 3 month out of network retail benefit type: Preferred Brand cost type: Copay qualifiers: No Charge value: 100 $ (Details: unknown codeUSD = 'United States dollar') cost type: Coinsurance qualifiers: After Deductible value: 0 % (Details: UCUM code% = '%') specificCost category: 1 month in network retail benefit type: Non-preferred Brand cost type: Copay qualifiers: No Charge value: 70 $ (Details: unknown codeUSD = 'United States dollar') cost type: Coinsurance qualifiers: After Deductible value: 0 % (Details: UCUM code% = '%') specificCost category: 1 month out of network retail benefit type: Non-preferred Brand cost type: Copay qualifiers: No Charge value: 70 $ (Details: unknown codeUSD = 'United States dollar') cost type: Coinsurance qualifiers: After Deductible value: 0 % (Details: UCUM code% = '%') specificCost category: 3 month in network retail benefit type: Non-preferred Brand cost type: Copay qualifiers: No Charge value: 140 $ (Details: unknown codeUSD = 'United States dollar') cost type: Coinsurance qualifiers: After Deductible value: 0 % (Details: UCUM code% = '%') specificCost category: 3 month out of network retail benefit type: Non-preferred Brand cost type: Copay qualifiers: No Charge value: 140 $ (Details: unknown codeUSD = 'United States dollar') cost type: Coinsurance qualifiers: After Deductible value: 0 % (Details: UCUM code% = '%') specificCost category: 1 month in network retail benefit type: Specialty cost type: Copay qualifiers: No Charge value: 100 $ (Details: unknown codeUSD = 'United States dollar') cost type: Coinsurance qualifiers: After Deductible value: 0 % (Details: UCUM code% = '%') specificCost category: 1 month out of network retail benefit type: Specialty cost type: Copay qualifiers: No Charge value: 100 $ (Details: unknown codeUSD = 'United States dollar') cost type: Coinsurance qualifiers: After Deductible value: 0 % (Details: UCUM code% = '%') specificCost category: 3 month in network retail benefit type: Specialty cost type: Copay qualifiers: No Charge value: 200 $ (Details: unknown codeUSD = 'United States dollar') cost type: Coinsurance qualifiers: After Deductible value: 0 % (Details: UCUM code% = '%') specificCost category: 3 month out of network retail benefit type: Specialty cost type: Copay qualifiers: No Charge value: 200 $ (Details: unknown codeUSD = 'United States dollar') cost type: Coinsurance qualifiers: After Deductible value: 0 % (Details: UCUM code% = '%')
Sample Medicare Advantage Plan Marketing Website
Sample Medicare Advantage Drug Plan Benefit Website
Sample Medicare Advantage Drug Plan Formulary Website