Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Barbour |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Berkeley |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Boone |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 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 |
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Braxton |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Brooke |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Cabell |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 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 |
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Calhoun |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Clay |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Doddridge |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 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 |
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Fayette |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Gilmer |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Grant |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $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 |
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Greenbrier |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Hampshire |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Hancock |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $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 |
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Hardy |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Harrison |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Jackson |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $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 |
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Jefferson |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Kanawha |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Lewis |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $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 |
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Lincoln |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Logan |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
McDowell |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $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 |
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Marion |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Marshall |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Mason |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $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 |
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Mercer |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Mineral |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Mingo |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 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 |
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Monongalia |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Monroe |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Morgan |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 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 |
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Nicholas |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Ohio |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Pendleton |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 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 |
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Pleasants |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Pocahontas |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Preston |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $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 |
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Putnam |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Raleigh |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Randolph |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $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 |
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Ritchie |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Roane |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Summers |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 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 |
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Taylor |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Tucker |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
|
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|
Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Tyler |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $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 |
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Upshur |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Wayne |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Webster |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $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 |
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Wetzel |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Wirt |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Wood |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $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 |
Humana Value Plus H5216-125 (PPO) in WV - H5216-125-0
Benefit Details
|
Wyoming |
$15.90 |
$480 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|