HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Bartholomew |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Benton |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Blackford |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 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 H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Brown |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Carroll |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Cass |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 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 H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Clay |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Clinton |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Crawford |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 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 H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Daviess |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Dearborn |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Decatur |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 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 H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Dubois |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Elkhart |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Fayette |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 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 H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Fountain |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Franklin |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Fulton |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 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 H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Gibson |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Grant |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Greene |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 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 H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Henry |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Howard |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Jackson |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 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 H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Jasper |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Jay |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Jefferson |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 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 H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Jennings |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Knox |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Lagrange |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 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 H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Lake |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
La Porte |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Lawrence |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 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 H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Marshall |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Martin |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Miami |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 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 H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Monroe |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Montgomery |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Newton |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 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 H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Ohio |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Orange |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Owen |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 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 H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Parke |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Perry |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Pike |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 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 H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Porter |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Posey |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Pulaski |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 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 H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Putnam |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Randolph |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Ripley |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 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 H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Rush |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
St. Joseph |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Scott |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 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 H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Shelby |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Spencer |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Starke |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 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 H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Steuben |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Sullivan |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Switzerland |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 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 H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Tippecanoe |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Tipton |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Union |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 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 H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Vanderburgh |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Vermillion |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Vigo |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 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 H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Wabash |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Warren |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Warrick |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 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 H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Washington |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
Wayne |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in IN - H5216-111-0
Benefit Details
|
White |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 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 H5216-111 (PPO) in KY - H5216-111-0
Benefit Details
|
Henderson |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in KY - H5216-111-0
Benefit Details
|
McCracken |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-111 (PPO) in KY - H5216-111-0
Benefit Details
|
Webster |
$15.00 |
$100 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $4,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|