Initial Coverage:
tooltip_Until yearly drug costs reach $3,310, you'll pay..._2021
Coverage Gap
tooltip_After costs paid by you and the drug plan are greater than $3,310 and your out-of-pocket is less than $4,850, you'll pay..._2021
Catastrophic Coverage
tooltip_After your out-of-pocket costs plus the amount of the drug manufacturer's discounts reach $4,850, you'll pay…_2021
Prescription Drug Coverage
Prescription Drug Deductible |
$0 |
In-Network Prescription Drug Coverage - Initial Coverage |
Tier 1 - Preferred Generics
|
Coverage in the coverage gap |
This plan has coverage in the Part D coverage gap. Tier 1 (preferred generic drugs) and Tier 2 (generic drugs) 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 $3 for Tier 1 medications at a preferred pharmacy. You pay no more than $10 for Tier 2 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. |
Out of Network Coverage
Prescription Drugs | Normally, we 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 3 of the Evidence of Coverage provides a full list of situations in which we may cover drugs from an out-of-network pharmacy. (See "Plan Documents" below.) |
Plan Documents
Summary of Benefits (PDF) | |
Evidence of Coverage (PDF) | |
Plan Rating (PDF) | |
General Transition Notice (PDF) | |
Low Income Subsidy Premium Summary Table for Those Receiving Extra Help (PDF) | |
Comprehensive Formulary (PDF) | |
Annual Notice of Change | |
Service Area Map | |
Enrollment Form |
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Member Account
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Health Club Discounts
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Care Coordination Team
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