Download Medicare Advantage HumanaChoice PPO R-5826-005 - QOOQe PDF

TitleMedicare Advantage HumanaChoice PPO R-5826-005 - QOOQe
LanguageEnglish
File Size1.0 MB
Total Pages56
Document Text Contents
Page 1

R5826005SBVAS14Y0040_GNHH4HIHH_14 Accepted

2014
Summary of Benefits
Extra Services and Programs

SBV026

HumanaChoice®

R5826-005 (Regional PPO)
Region 9
State of Florida

Page 28

26 – 2014 SUMMARY OF BENEFITS

If you have any questions about this plan's benefits or costs, please contact HUMANA INSURANCE COMPANY for details.

PRESCRIPTION DRUG BENEFITS
BENEFIT ORIGINAL MEDICARE HumanaChoice R5826-005 (Regional

PPO)
� $85 copayment for a one-month

(30-day) supply of drugs in this tier from
a non-preferred mail order pharmacy.

� $255 copayment for a three-month
(90-day) supply of drugs in this tier from
a non-preferred mail order pharmacy.

• Not all drugs on this tier are available at
this extended day supply. Please contact
the plan for more information.

• Tier 5: Specialty Tier
� 33% coinsurance for a one-month

(30-day) supply of drugs in this tier from
a preferred mail order pharmacy.

� 33% coinsurance for a one-month
(30-day) supply of drugs in this tier from
a non-preferred mail order pharmacy.

Coverage Gap
• After your total yearly drug costs reach

$2,850, you receive limited coverage by
the plan on certain drugs. You will also
receive a discount on brand name drugs
and generally pay no more than 47.5% for
the plan's costs for brand drugs and 72%
of the plan's costs for generic drugs until
your yearly out-of-pocket drug costs reach
$4,550.

Additional Coverage Gap
• The plan covers few formulary generics

(less than 10% of formulary generic drugs),
few formulary brands (less than 10% of
formulary brand drugs) through the
coverage gap.

• The plan offers additional coverage in the
gap for the following tiers.

• You pay the following:
Retail Pharmacy
• Contact your plan if you have questions

about cost-sharing or billing when less
than a one-month supply is dispensed.

• Tier 1: Preferred Generic
� $3 copayment for a one-month

(30-day) supply of certain drugs covered
within this tier

� $9 copayment for a three-month
(90-day) supply of certain drugs covered
within this tier

(Prescription Drug Benefits - Continued on next page)

Page 29

2014 SUMMARY OF BENEFITS – 27

If you have any questions about this plan's benefits or costs, please contact HUMANA INSURANCE COMPANY for details.

PRESCRIPTION DRUG BENEFITS
BENEFIT ORIGINAL MEDICARE HumanaChoice R5826-005 (Regional

PPO)
• Not all drugs on this tier are available at

this extended day supply. Please contact
the plan for more information.

• Tier 2: Non-Preferred Generic
� $8 copayment for a one-month

(30-day) supply of certain drugs covered
within this tier

� $24 copayment for a three-month
(90-day) supply of certain drugs covered
within this tier

• Not all drugs on this tier are available at
this extended day supply. Please contact
the plan for more information.

• Tier 3: Preferred Brand
� $40 copayment for a one-month

(30-day) supply of certain drugs covered
within this tier

� $120 copayment for a three-month
(90-day) supply of certain drugs covered
within this tier

• Not all drugs on this tier are available at
this extended day supply. Please contact
the plan for more information.

• Tier 4: Non-Preferred Brand
� $85 copayment for a one-month

(30-day) supply of certain drugs covered
within this tier

� $255 copayment for a three-month
(90-day) supply of certain drugs covered
within this tier

• Not all drugs on this tier are available at
this extended day supply. Please contact
the plan for more information.

• Tier 5: Specialty Tier
� 33% coinsurance for a one-month

(30-day) supply of certain drugs covered
within this tier

Long Term Care Pharmacy
• Long term care pharmacies must dispense

brand name drugs in amounts less than a
14 days supply at a time. They may also
dispense less than a month's supply of
generic drugs at a time. Contact your plan
if you have questions about cost-sharing or
billing when less than a one-month supply
is dispensed.

• Tier 1: Preferred Generic

(Prescription Drug Benefits - Continued on next page)

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