Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Adams |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Alamosa |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Arapahoe |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 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 H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Archuleta |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Bent |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Boulder |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 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 H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Broomfield |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
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Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Chaffee |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Clear Creek |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 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 H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Conejos |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Costilla |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Crowley |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 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 H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Custer |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Delta |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Denver |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 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 H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Dolores |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Douglas |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Elbert |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 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 H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
El Paso |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Fremont |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Gilpin |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 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 H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Grand |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Gunnison |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Hinsdale |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 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 H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Huerfano |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Jackson |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Jefferson |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 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 H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Lake |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
La Plata |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Larimer |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 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 H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Las Animas |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Lincoln |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Logan |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 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 H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Mesa |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Mineral |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Montezuma |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 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 H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Montrose |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Morgan |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Otero |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 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 H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Ouray |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Park |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Pueblo |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 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 H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Rio Blanco |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Rio Grande |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Saguache |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 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 H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
San Juan |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
San Miguel |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
|
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Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Summit |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 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 H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Teller |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Washington |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Humana Value Plus H5216-195 (PPO) in CO - H5216-195-0
Benefit Details
|
Weld |
$33.90 |
$435 Tier 1 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| $7,550 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|