Resumen de cobertura
¿Está mi médico en la red?
Beneficio: | Usted paga: |
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Visita al médico de cabecera | $0 copay |
Visita al especialista | $0 copay |
Atención para pacientes hospitalizados | $0 copay |
Servicios de emergencia (dentro y fuera de la red) | $0 copay |
Servicios de urgencia | $0 copay in and out-of-network |
Cobertura para Medicinas Recetadas
Beneficio: | Usted paga: |
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Deducible para medicinas recetadas | $0 or up to $480. |
Cobertura de medicinas recetadas dentro de la red - Cobertura inicial | Tier 1 - Preferred Generics* |
Cobertura durante la brecha en la cobertura | This plan has coverage in the Part D coverage gap. Tier 1 (preferred generic drugs) and Tier 2 (generics) 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 network retail pharmacy. You pay no more than $0 for Tier 2 medications at a network retail 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. |
Cobertura para Eventos Catastróficos | You pay the greater of $3.95 or 5% for generic drugs and drugs treated like generics. You pay the greater of $9.85 or 5% for brand name drugs. |
Cobertura adicional
Beneficio: | |
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Beneficios Adicionales | Routine Dental |
Cobertura Fuera de la Red:
Beneficio: | |
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Servicios/Suministros médicos | 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. |
Medicinas recetadas | 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. |
Documentos del plan
Resumen de beneficios (PDF) |
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Constancia de Cobertura (PDF) |
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Calificación del plan (PDF) |
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Notificación general de transición (PDF) |
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Tabla de resumen de subsidios para la prima por bajos ingresos para quienes reciben ayuda adicional (PDF) |
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Formulario completo (PDF) |
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Mapa de áreas de servicio | |
Notificación Anual de Cambios |
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Formulario de Inscripción |
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