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2019 Medicare Prescription Drug Plan Cost-Sharing Details
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.
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2019 Medicare Advantage Prescription Drug
Formulary (Drug List) Cost-Sharing Details
HumanaChoice H5216-013 (PPO) (H5216-013-0)
Benefit Details        
This plan is available in Adams County, IL

Monthly Premium: $79.00
Rx Deductible: $0
Initial Coverage Limit: $3,820

Click on a letter below to view the
HumanaChoice H5216-013 (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 
This Plan Uses Lower Cost-Sharing for Preferred Pharmacies
  30-Day Supply
Cost-Sharing		 90-Day Supply
Cost-Sharing
Preferred Pharmacy Standard Pharmacy Mail- Order* Preferred Pharmacy Standard Pharmacy Mail- Order*
This plan does not have an Initial Deductible:n/an/an/an/an/an/a
Initial Coverage Phase Cost-Sharing
Tier 1: Preferred Generic: $6.00 $10.00 $6.00 $18.00 $30.00 $0.00
Tier 2: Generic: $15.00 $20.00 $15.00 $45.00 $60.00 $0.00
Tier 3: Preferred Brand: $47.00 $47.00 $47.00 $141.00 $141.00 $131.00
Tier 4: Non-Preferred Drug: $100.00 $100.00 $100.00 $300.00 $300.00 $290.00
Tier 5: Specialty Tier: 33% 33% 33% n/a n/a n/a
Coverage Gap (Donut Hole) Phase Cost Sharing
Plan offers no Gap Coverage -- 63% Generic and 75% Brand Donut Hole Discount applies
All Formulary Generic Drugs: 37% 37% 37% 37% 37% 37%
All Formulary Brand-Name Drugs: 25% 25% 25% 25% 25% 25%
Catastrophic Coverage Phase Cost Sharing
Generic & Preferred Multi-Source Drugs: The greater of 5% or $3.40 The greater of 5% or $3.40
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): The greater of 5% or $8.50 The greater of 5% or $8.50
Go to the HumanaChoice H5216-013 (PPO) 2019 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 
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