2024 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
HumanaChoice H5216-100 (PPO) (H5216-100-0) Benefits & Contact Info all covered insulin pay $35 or less | ||||||
This plan is available in Dickenson County, VA Click on a letter below to view the HumanaChoice H5216-100 (PPO) Formulary A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 0-9 | ||||||
30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing |
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Preferred Pharmacy | Standard Pharmacy | Mail- Order* | Preferred Pharmacy | Standard Pharmacy | Mail- Order* | |
This plan does not have an Initial Deductible: | n/a | n/a | n/a | n/a | n/a | n/a |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: Preferred Generic: | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Tier 2: Generic: | $5.00 | $5.00 | $5.00 | $15.00 | $15.00 | $0.00 |
Tier 3: Preferred Brand: | $47.00 | $47.00 | $47.00 | $141.00 | $141.00 | $131.00 |
Tier 4: Non-Preferred Drug: | $97.00 | $97.00 | $97.00 | $291.00 | $291.00 | $281.00 |
Tier 5: : | 33% | 33% | 33% | n/a | n/a | n/a |
Coverage Gap (Donut Hole) Phase Cost Sharing Plan offers no Gap Coverage -- 75% Generic and 75% Brand Donut Hole Discount applies | ||||||
All Formulary Generic Drugs: | 25% | 25% | 25% | 25% | 25% | 25% |
All Formulary Brand-Name Drugs: | 25% | 25% | 25% | 25% | 25% | 25% |
Catastrophic Coverage Phase Cost Sharing | ||||||
All Formulary Drugs: |
$0 cost-sharing. The Inflation Reduction Act (IRA) of 2022 eliminates beneficiary cost-sharing once your TrOOP reaches the established maximum cap on out-of-pocket spending for Part D formulary drugs (RxMOOP). | |||||
Go to the HumanaChoice H5216-100 (PPO) 2024 Formulary Browser by choosing a letter below: A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 0-9 |