HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Anderson |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Aransas |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Armstrong |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $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 H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Atascosa |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Austin |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Bandera |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $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 H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Bee |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Bexar |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Callahan |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $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 H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Camp |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Carson |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Chambers |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $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 H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Cherokee |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Coleman |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Collin |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $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 H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Colorado |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Comal |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Comanche |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $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 H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Cooke |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Dallas |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Dawson |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $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 H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Deaf Smith |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Delta |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Denton |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $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 H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Dimmit |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Eastland |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Ector |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $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 H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Edwards |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Ellis |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Erath |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $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 H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Fannin |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Fort Bend |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Franklin |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $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 H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Frio |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Gray |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Grayson |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $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 H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Gregg |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Guadalupe |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Hardin |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $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 H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Harris |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Harrison |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Henderson |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $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 H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Hood |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Howard |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Jefferson |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $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 H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Jim Wells |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Johnson |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Jones |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $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 H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Kendall |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Kinney |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Kleberg |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $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 H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Liberty |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Marion |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Martin |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $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 H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Maverick |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Medina |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Midland |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $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 H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Montgomery |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Morris |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Navarro |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $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 H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Nueces |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Orange |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Palo Pinto |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $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 H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Panola |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Polk |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Potter |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $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 H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Randall |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Real |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Rockwall |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $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 H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Rusk |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
San Jacinto |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
San Patricio |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $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 H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Shackelford |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Shelby |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Smith |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $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 H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Tarrant |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Taylor |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Tyler |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $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 H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Upshur |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Uvalde |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Van Zandt |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $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 H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Victoria |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Walker |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Waller |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $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 H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Washington |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Webb |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Wharton |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $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 H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Wilson |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Wood |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-042 (PPO) in TX - H5216-042-0
Benefit Details
|
Zavala |
$92.00 |
$175 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|