HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Arkansas |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Baxter |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Benton |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Boone |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Bradley |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Calhoun |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Carroll |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Chicot |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Clark |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Cleburne |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Cleveland |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Conway |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Craighead |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Crawford |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Dallas |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Desha |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Faulkner |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Franklin |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Fulton |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Garland |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Grant |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Greene |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Hot Spring |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Izard |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Jefferson |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Johnson |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Lee |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Lincoln |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Logan |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Lonoke |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Madison |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Marion |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Montgomery |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Nevada |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Newton |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Perry |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Phillips |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Pike |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Poinsett |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Pope |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Prairie |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Pulaski |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Randolph |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
St. Francis |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Saline |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Scott |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Searcy |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Sebastian |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Stone |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Union |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Van Buren |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Washington |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in AR - H5216-083-0
Benefit Details
|
Yell |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in KS - H5216-083-0
Benefit Details
|
Cherokee |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in KS - H5216-083-0
Benefit Details
|
Crawford |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in KS - H5216-083-0
Benefit Details
|
Labette |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in MO - H5216-083-0
Benefit Details
|
Jasper |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in MO - H5216-083-0
Benefit Details
|
McDonald |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in MO - H5216-083-0
Benefit Details
|
Newton |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Adair |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Bryan |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Caddo |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Canadian |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Carter |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Cherokee |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Cleveland |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Comanche |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Craig |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Creek |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Delaware |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Dewey |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Garvin |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Grady |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Haskell |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Hughes |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Johnston |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Kay |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Kingfisher |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Kiowa |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Latimer |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Le Flore |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Lincoln |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Logan |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
McClain |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
McIntosh |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Mayes |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Murray |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Muskogee |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Noble |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Nowata |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Okfuskee |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Oklahoma |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Okmulgee |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Osage |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Ottawa |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Pawnee |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Payne |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Pittsburg |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Pontotoc |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Pottawatomie |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Pushmataha |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Rogers |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Seminole |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Sequoyah |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Stephens |
$77.00 |
$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%
select insulin pay $35 copay | $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 H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Tulsa |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-083 (PPO) in OK - H5216-083-0
Benefit Details
|
Wagoner |
$77.00 |
$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%
select insulin pay $35 copay | $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|