HumanaChoice H5216-137 (PPO) in AZ - H5216-137-0
Benefit Details
|
Cochise |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in AZ - H5216-137-0
Benefit Details
|
Gila |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in AZ - H5216-137-0
Benefit Details
|
Graham |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in AZ - H5216-137-0
Benefit Details
|
Greenlee |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in AZ - H5216-137-0
Benefit Details
|
La Paz |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in AZ - H5216-137-0
Benefit Details
|
Maricopa |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in AZ - H5216-137-0
Benefit Details
|
Mohave |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in AZ - H5216-137-0
Benefit Details
|
Pima |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in AZ - H5216-137-0
Benefit Details
|
Pinal |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in AZ - H5216-137-0
Benefit Details
|
Santa Cruz |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in AZ - H5216-137-0
Benefit Details
|
Yavapai |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in AZ - H5216-137-0
Benefit Details
|
Yuma |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Adams |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Alamosa |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Arapahoe |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Archuleta |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Bent |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Boulder |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Broomfield |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Chaffee |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Clear Creek |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Conejos |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Costilla |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Crowley |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Custer |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Delta |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Denver |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Dolores |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Douglas |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Elbert |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
El Paso |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Fremont |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Gilpin |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Grand |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Gunnison |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Hinsdale |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Huerfano |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Jackson |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Jefferson |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Lake |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
La Plata |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Larimer |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Las Animas |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Lincoln |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Logan |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Mesa |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Mineral |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Montezuma |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Montrose |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Morgan |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Otero |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Ouray |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Park |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Pueblo |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Rio Blanco |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Rio Grande |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Saguache |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
San Juan |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
San Miguel |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Summit |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Teller |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Washington |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in CO - H5216-137-0
Benefit Details
|
Weld |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in NM - H5216-137-0
Benefit Details
|
Bernalillo |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in NM - H5216-137-0
Benefit Details
|
Catron |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in NM - H5216-137-0
Benefit Details
|
Chaves |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in NM - H5216-137-0
Benefit Details
|
Colfax |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in NM - H5216-137-0
Benefit Details
|
Curry |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in NM - H5216-137-0
Benefit Details
|
DeBaca |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in NM - H5216-137-0
Benefit Details
|
Dona Ana |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in NM - H5216-137-0
Benefit Details
|
Eddy |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in NM - H5216-137-0
Benefit Details
|
Grant |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in NM - H5216-137-0
Benefit Details
|
Guadalupe |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in NM - H5216-137-0
Benefit Details
|
Lea |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in NM - H5216-137-0
Benefit Details
|
Lincoln |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in NM - H5216-137-0
Benefit Details
|
Los Alamos |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in NM - H5216-137-0
Benefit Details
|
Luna |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in NM - H5216-137-0
Benefit Details
|
Mora |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in NM - H5216-137-0
Benefit Details
|
Otero |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in NM - H5216-137-0
Benefit Details
|
Quay |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in NM - H5216-137-0
Benefit Details
|
Rio Arriba |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in NM - H5216-137-0
Benefit Details
|
Roosevelt |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in NM - H5216-137-0
Benefit Details
|
Sandoval |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in NM - H5216-137-0
Benefit Details
|
San Juan |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in NM - H5216-137-0
Benefit Details
|
San Miguel |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in NM - H5216-137-0
Benefit Details
|
Santa Fe |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in NM - H5216-137-0
Benefit Details
|
Sierra |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in NM - H5216-137-0
Benefit Details
|
Socorro |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in NM - H5216-137-0
Benefit Details
|
Taos |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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HumanaChoice H5216-137 (PPO) in NM - H5216-137-0
Benefit Details
|
Torrance |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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Plan Name |
County |
Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice H5216-137 (PPO) in NM - H5216-137-0
Benefit Details
|
Valencia |
$0.00 |
$445 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $45.00 Non-Preferred Drug: $99.00 Specialty Tier: 25%
all covered insulin pay $35 or less | $7,350 Browse Formulary |
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