Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Barbour |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
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Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Berkeley |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
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Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Boone |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a 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 |
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Braxton |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
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Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Brooke |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
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Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Cabell |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a 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 |
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Calhoun |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
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Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Clay |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
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Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Doddridge |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a 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 |
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Gilmer |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
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Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Grant |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
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Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Greenbrier |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a 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 |
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Hancock |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
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Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Hardy |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Harrison |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a 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 |
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Jackson |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
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Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Jefferson |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
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Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Kanawha |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a 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 |
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Lewis |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Logan |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
McDowell |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a 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 |
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Marion |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Marshall |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Mason |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a 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 |
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Mercer |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Mingo |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Monroe |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a 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 |
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Nicholas |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Ohio |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Pendleton |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a 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 |
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Pocahontas |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Putnam |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Raleigh |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a 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 |
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Randolph |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Ritchie |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Roane |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a 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 |
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Summers |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Taylor |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Tucker |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a 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 |
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Tyler |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Upshur |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Wayne |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a 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 |
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Webster |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Wetzel |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Wood |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a 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 |
Humana Gold Choice H8145-051 (PFFS) in WV - H8145-051-0
Benefit Details
|
Wyoming |
$71.00 |
$320 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $9.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|