HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Barrow |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Bartow |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Bryan |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a 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 - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Burke |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Butts |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Carroll |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a 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 - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Chatham |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Chattahoochee |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Cherokee |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a 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 - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Clarke |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Clayton |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Cobb |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a 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 - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Columbia |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Coweta |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Dawson |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a 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 - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
DeKalb |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Douglas |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Effingham |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a 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 - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Fayette |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Floyd |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Forsyth |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a 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 - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Fulton |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Gordon |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Gwinnett |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a 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 - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Hall |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Haralson |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Harris |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a 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 - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Heard |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Henry |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Jackson |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a 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 - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Jasper |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Lamar |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Liberty |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a 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 - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Lincoln |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
McDuffie |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Madison |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a 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 - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Marion |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Meriwether |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Muscogee |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a 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 - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Newton |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Oconee |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Oglethorpe |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a 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 - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Paulding |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Pickens |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Pike |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a 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 - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Polk |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Richmond |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Rockdale |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a 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 - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Spalding |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Troup |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Upson |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a 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 - Diabetes (PPO C-SNP) in GA - H5216-246-0
Benefit Details
|
Walton |
$0.00 |
$145 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|