Plan Details
Costs and Other Important Information
Benefits
20% per visit
Specialist:
20% per visit
20%
Urgent care:
20%
20%
Lab services:
20%
Diagnostic radiology services (e.g., MRI):
20%
Outpatient x-rays:
20%
Outpatient group therapy visit with a psychiatrist:
20%
Outpatient individual therapy visit with a psychiatrist:
20%
Outpatient group therapy visit:
20%
Outpatient individual therapy visit:
20%
20%
Physical therapy and speech and language therapy visit:
20%
20%
Routine foot care:
20%
20% per item
Prosthetics (e.g., braces, artificial limbs):
20% per item
Diabetes supplies:
20% per item
20%
Other Part B drugs:
20%
Coverage Area for Humana Walmart Rx (PDP)
State | Missouri |
---|---|
County | St. Louis |
Cost Sharing Information
All cost-sharing assumes in-network healthcare providers.
Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit
30 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
---|---|---|---|
Tier 1: Preferred Generic | $1 copay | $10 copay | $1 copay |
Tier 2: Non-Preferred Generic | $4 copay | $20 copay | $4 copay |
Tier 3: Preferred Brand Name | 23% coinsurance | 25% coinsurance | 23% coinsurance |
Tier 4: Non-Preferred Brand Name | 35% coinsurance | 50% coinsurance | 35% coinsurance |
Tier 5: Specialty Tier | 25% coinsurance | 25% coinsurance | 25% coinsurance |
90 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
---|---|---|---|
Tier 1: Preferred Generic | $3 copay | $30 copay | $0 copay |
Tier 2: Non-Preferred Generic | $12 copay | $60 copay | $8 copay |
Tier 3: Preferred Brand Name | 23% coinsurance | 25% coinsurance | 20% coinsurance |
Tier 4: Non-Preferred Brand Name | 35% coinsurance | 50% coinsurance | 35% coinsurance |
Tier 5: Specialty Tier |