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2021 Medicare Prescription Drug Plan Cost-Sharing Details
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.
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2021 Medicare Advantage Prescription Drug
Formulary (Drug List) Cost-Sharing Details
HumanaChoice R5495-002 (Regional PPO) (R5495-002-0)
Benefit Details        
This plan is available in Statewide County, OH

Monthly Premium: $39.00
Rx Deductible: $380
Initial Coverage Limit: $4,130

Click on a letter below to view the
HumanaChoice R5495-002 (Regional PPO) Formulary
A  B  C  D  E  F  G  H  I  J  K  L  M  N  O  P  Q  R  S  T  U  V  W  X  Y  Z  0-9 
This Plan Uses Lower Cost-Sharing for Preferred Pharmacies
  30-Day Supply
Cost-Sharing		 90-Day Supply
Cost-Sharing
Preferred Pharmacy Standard Pharmacy Mail- Order* Preferred Pharmacy Standard Pharmacy Mail- Order*
Initial Deductible Phase Cost Sharing
Tier 1: Preferred Generic: $16.00(E) $16.00(E) $16.00(E) $48.00(E) $48.00(E) $0.00(E)
Tier 2: Generic: 100% 100% 100% 100% 100% 100%
Tier 3: Preferred Brand: 100% 100% 100% 100% 100% 100%
Tier 4: Non-Preferred Drug: 100% 100% 100% 100% 100% 100%
Tier 5: Specialty Tier: 100% 100% 100% 100% 100% 100%
Initial Coverage Phase Cost-Sharing
Tier 1: Preferred Generic: $16.00 $16.00 $16.00 $48.00 $48.00 $0.00
Tier 2: Generic: $19.00 $20.00 $19.00 $57.00 $60.00 $0.00
Tier 3: Preferred Brand: $47.00 $47.00 $47.00 $141.00 $141.00 $131.00
Tier 4: Non-Preferred Drug: $100.00 $100.00 $100.00 $300.00 $300.00 $290.00
Tier 5: Specialty Tier: 26% 26% 26% n/a n/a n/a
Coverage Gap (Donut Hole) Phase Cost Sharing
Plan offers no Gap Coverage -- 75% Generic and 75% Brand Donut Hole Discount applies
All Formulary Generic Drugs: 25% 25% 25% 25% 25% 25%
All Formulary Brand-Name Drugs: 25% 25% 25% 25% 25% 25%
Catastrophic Coverage Phase Cost Sharing
Generic & Preferred Multi-Source Drugs: The greater of 5% or $3.70 The greater of 5% or $3.70
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): The greater of 5% or $9.20 The greater of 5% or $9.20
Notes:
*The mail-order cost-sharing is the plan’s "preferred" mail-order cost-sharing.
(E) Drugs on this tier are excluded from the Initial Deductible and do not count toward meeting the deductible.
Go to the HumanaChoice R5495-002 (Regional PPO) 2021 Formulary Browser by choosing a letter below:
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