HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Adair |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Allamakee |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Appanoose |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 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 |
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Audubon |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Buena Vista |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Butler |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 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 |
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Calhoun |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Carroll |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Cass |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 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 |
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Cerro Gordo |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Cherokee |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Clayton |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 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 |
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Clinton |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Crawford |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Davis |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 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 |
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Decatur |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Dickinson |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Emmet |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 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 |
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Floyd |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Franklin |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Fremont |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 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 |
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Grundy |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Hamilton |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Hancock |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 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 |
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Hardin |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Harrison |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Henry |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 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 |
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Humboldt |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Ida |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Jackson |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 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 |
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Jefferson |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Keokuk |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Kossuth |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 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 |
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Lee |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Lucas |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Lyon |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 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 |
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Mahaska |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Mills |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Monona |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 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 |
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Monroe |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
O'Brien |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Osceola |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 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 |
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Page |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Palo Alto |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Plymouth |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 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 |
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Pocahontas |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Poweshiek |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Ringgold |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 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 |
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Sac |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Sioux |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
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HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Tama |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 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 |
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Union |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Van Buren |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Wapello |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 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 |
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Wayne |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Webster |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Winnebago |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 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 |
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Winneshiek |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Woodbury |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Worth |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 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 |
HumanaChoice H5216-091 (PPO) in IA - H5216-091-0
Benefit Details
|
Wright |
$87.00 |
$375 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $16.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|