Initial Coverage:
tooltip_Until yearly drug costs reach $3,310, you'll pay..._2022
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..._2022
Catastrophic Coverage
tooltip_After your out-of-pocket costs plus the amount of the drug manufacturer's discounts reach $4,850, you'll pay…_2022
Prescription Drug Coverage
| Prescription Drug Deductible |
$480 (aplica a los Niveles 3, 4 y 5) |
| In-Network Prescription Drug Coverage - Initial Coverage |
Nivel 1 - Genéricas preferidas
|
| Coverage in the coverage gap |
Usted no paga más del 25% del costo por medicinas genéricas preferidas, genéricas y genéricas especializadas. Usted no paga más del 25% del costo por medicinas de marca y especializadas no genéricas durante la brecha en la cobertura. |
| Catastrophic Coverage |
Usted paga la cantidad que sea mayor entre $3.95 o el 5% por medicinas genéricas o consideradas genéricas. Usted paga la cantidad que sea mayor entre $9.85 o el 5% por medicinas de marca. |
Out of Network Coverage
| Prescription Drugs | Este plan no cubre medicinas que se obtienen en una farmacia fuera de la red. |
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) |
|
| BlueMedicare RX (PDP) Comprehensive Formulary (PDF) |
|
| Service Area Map | |
| Annual Notice of Change |
|
| Enrollment Form |
|