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 |
$405 (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 paga no más del 25% del costo por medicinas genéricas preferidas, genéricas y genéricas especializadas. Usted paga no 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 $3.70 o el 5% por medicinas genéricas o consideradas genéricas. Usted paga la cantidad que sea mayor entre $9.20 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) | |
| Comprehensive Formulary (PDF) | |
| Annual Notice of Change | |
| Service Area Map | |
| Enrollment Form |