HumanaChoice H5216-109 (PPO) in KY - H5216-109-0
Benefit Details
|
Boone |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in KY - H5216-109-0
Benefit Details
|
Campbell |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in KY - H5216-109-0
Benefit Details
|
Grant |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 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 H5216-109 (PPO) in KY - H5216-109-0
Benefit Details
|
Kenton |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in KY - H5216-109-0
Benefit Details
|
Pendleton |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Adams |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 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 H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Allen |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Athens |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Auglaize |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 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 H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Belmont |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Brown |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Butler |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 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 H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Champaign |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Clark |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Clermont |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 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 H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Clinton |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Crawford |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Darke |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 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 H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Defiance |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Delaware |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Erie |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 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 H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Fairfield |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Fayette |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Franklin |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 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 H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Fulton |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Gallia |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Greene |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 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 H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Guernsey |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Hamilton |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Hancock |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 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 H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Hardin |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Henry |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Highland |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 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 H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Hocking |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Jackson |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Lawrence |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 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 H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Licking |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Logan |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Lucas |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 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 H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Madison |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Marion |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Meigs |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 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 H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Mercer |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Miami |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Monroe |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 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 H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Montgomery |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Morgan |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Morrow |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 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 H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Muskingum |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Noble |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Ottawa |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 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 H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Paulding |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Perry |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Pickaway |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 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 H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Pike |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Preble |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Putnam |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 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 H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Ross |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Sandusky |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Scioto |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 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 H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Seneca |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Shelby |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Union |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 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 H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Van Wert |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Vinton |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Warren |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 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 H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Washington |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Williams |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Wood |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 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 H5216-109 (PPO) in OH - H5216-109-0
Benefit Details
|
Wyandot |
$19.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|