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 (applies to tiers 3, 4, 5) |
| In-Network Prescription Drug Coverage - Initial Coverage |
Tier 1 - Preferred Generics
|
| Coverage in the coverage gap |
You pay no more than 25% of the costs for preferred generic, generic and generic specialty drugs. You pay no more than 25% of the costs for brand name drugs and non-generic specialty drugs in the coverage gap. |
| 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 | This plan does not cover drugs filled at an out-of-network pharmacy. |
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 |