Coverage Summary
Is My Doctor In-Network?
Benefit: | You Pay: |
---|---|
Primary Care Doctor Visit | $10 copay in-network |
Specialist Visit | $50 copay in-network |
Inpatient Hospital Care | $345 copay per day for days 1-5 in-network |
Emergency Services (In and out-of-network) | $90 copay; ER copay waived if admitted |
Urgent Care Services | $50 copay in and out-of-network |
Prescription Drug Coverage
Benefit: | You Pay: |
---|---|
Prescription Drug Deductible | $250 (applies to Tiers 3, 4, 5) |
In-Network Prescription Drug Coverage - Initial Coverage | Tier 1 - Preferred Generics |
Coverage Gap | This plan has coverage in the Part D coverage gap. Tier 1 (preferred generic drugs) and Tier 6 (select care) medications are covered in the coverage gap. For these tiers, you continue to pay the same cost-sharing amounts as in the Initial Coverage Stage. You pay no more than $0 for Tier 1 medications at a preferred pharmacy. You pay no more than $0 for Tier 6 medications at a preferred pharmacy. You will pay no more than 25% of the costs for generics in all other tiers. For all brand drugs you pay no more than 25% of the costs. |
Catastrophic Coverage | You pay the greater of $3.70 or 5% for generic drugs and drugs treated like generics. You pay the greater of $9.20 or 5% for brand name drugs. |
Extra Coverage
Benefit: | |
---|---|
Extra Benefits | Routine Vision - Exam Only |
Out of Network Coverage
Benefit: | |
---|---|
Medical Services/Supplies | If you receive care from an out-of-network provider, your out-of-pocket costs will usually be higher than if you use a network provider. There are three exceptions: emergency care, urgently needed care and dialysis services. For details about the plan's coverage of out-of-network care, please refer to the Summary of Benefits or the Evidence of Coverage. (See "Plan Documents" below.) |
Prescription Drugs | We generally cover drugs filled at an out-of-network pharmacy only if you are not able to use one of our network pharmacies (for example, because you are traveling, need emergency or urgent care, or need a drug that it not available at an accessible network pharmacy). Chapter 5 of the Evidence of Coverage provides a full list of situations in which we may cover drugs from an out-of-network pharmacy. |
Plan Documents
Summary of Benefits (PDF) | |
Evidence of Coverage (PDF) | |
Plan Rating (PDF) | |
Comprehensive Formulary (PDF) | |
Service Area Map | |
Annual Notice of Change | |
Enrollment Forms | |
General Transition Notice (PDF) | |
Low Income Subsidy Premium Summary Table for Those Receiving Extra Help (PDF) |
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