Coverage Summary
Is My Doctor In-Network?
Benefit: | You Pay: |
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Primary Care Doctor Visit | $0 copay |
Specialist Visit | $35 copay |
Inpatient Hospital Care | $205 Copay Per Day 1-6 |
Emergency Services (In and out-of-network) | $90 copay; ER copay waived if admitted |
Urgent Care Services | $40 copay in and out-of-network |
Prescription Drug Coverage
Benefit: | You Pay: |
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Prescription Drug Deductible | $0 |
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. |
Extra Coverage
Benefit: | |
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Extra Benefits | Routine Dental |
Out of Network Coverage
Benefit: | |
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Medical Services/Supplies | If you receive care from an out-of network provider without prior authorization from our plan, the care will not be covered except for emergency care, urgently needed care and dialysis services. |
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) |
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Evidence of Coverage (PDF) |
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Plan Rating (PDF) |
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General Transition Notice (PDF) |
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Low Income Subsidy Premium Summary Table for Those Receiving Extra Help (PDF) |
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Comprehensive Formulary (PDF) |
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Service Area Map | |
Enrollment Forms |
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