HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Arkansas |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Baxter |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Benton |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 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 H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Boone |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Bradley |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Calhoun |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 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 H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Carroll |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Chicot |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Clark |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 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 H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Cleburne |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Cleveland |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Conway |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 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 H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Craighead |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Crawford |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Dallas |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 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 H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Desha |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Faulkner |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Franklin |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 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 H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Fulton |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Garland |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Grant |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 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 H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Greene |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Hot Spring |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Izard |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 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 H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Jefferson |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Johnson |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Lee |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 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 H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Lincoln |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Logan |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Lonoke |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 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 H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Madison |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Marion |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Montgomery |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 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 H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Nevada |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Newton |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Perry |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 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 H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Phillips |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Pike |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Poinsett |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 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 H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Pope |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Prairie |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Pulaski |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 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 H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Randolph |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
St. Francis |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Saline |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 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 H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Scott |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Searcy |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Sebastian |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 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 H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Stone |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Union |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Van Buren |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 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 H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Washington |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in AR - H5216-163-0
Benefit Details
|
Yell |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in KS - H5216-163-0
Benefit Details
|
Cherokee |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 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 H5216-163 (PPO) in KS - H5216-163-0
Benefit Details
|
Crawford |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in KS - H5216-163-0
Benefit Details
|
Labette |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in MO - H5216-163-0
Benefit Details
|
Gasconade |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 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 H5216-163 (PPO) in MO - H5216-163-0
Benefit Details
|
Jasper |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in MO - H5216-163-0
Benefit Details
|
McDonald |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in MO - H5216-163-0
Benefit Details
|
Maries |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 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 H5216-163 (PPO) in MO - H5216-163-0
Benefit Details
|
Newton |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in MO - H5216-163-0
Benefit Details
|
Perry |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-163 (PPO) in MO - H5216-163-0
Benefit Details
|
Pike |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 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 H5216-163 (PPO) in MO - H5216-163-0
Benefit Details
|
Ste. Genevieve |
$45.00 |
$195 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 29%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|