HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Aitkin |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Anoka |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Becker |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Beltrami |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Benton |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Big Stone |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Carlton |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Carver |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Cass |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Chippewa |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Chisago |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Clay |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Clearwater |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Crow Wing |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Dakota |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Douglas |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Grant |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Hennepin |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Hubbard |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Isanti |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Itasca |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Kanabec |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Kandiyohi |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Kittson |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Lac qui Parle |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Lake |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Lake of the Woods |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Lincoln |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Lyon |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
McLeod |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Mahnomen |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Marshall |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Meeker |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Mille Lacs |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Morrison |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Murray |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Nobles |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Norman |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Otter Tail |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Pennington |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Pine |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Pipestone |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Polk |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Pope |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Ramsey |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Red Lake |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Redwood |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Renville |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Rock |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Roseau |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
St. Louis |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Scott |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Sherburne |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Stearns |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Swift |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Todd |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Wadena |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 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 H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Washington |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Wilkin |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-063 (PPO) in MN - H5216-063-0
Benefit Details
|
Wright |
$107.00 |
$250 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $6.00 Preferred Brand: $47.00 Non-Preferred Drug: 50% Specialty Tier: 28%
| $3,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|