Resumen de cobertura
¿Está mi médico en la red?
Beneficio: | Usted paga: |
---|---|
Visita al médico de cabecera | $10 copay in-network |
Visita al especialista | $50 copay in-network |
Atención para pacientes hospitalizados | $345 copay per day for days 1-5 in-network |
Servicios de emergencia (dentro y fuera de la red) | $90 copay; ER copay waived if admitted |
Servicios de urgencia | $50 copay in and out-of-network |
Cobertura para Medicinas Recetadas
Beneficio: | Usted paga: |
---|---|
Deducible para medicinas recetadas | $250 (applies to Tiers 3, 4, 5) |
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 6 (select care) 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 preferred pharmacy. You pay no more than $0 for Tier 6 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. |
Cobertura para Eventos Catastróficos | 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. |
Cobertura adicional
Beneficio: | |
---|---|
Beneficios Adicionales | Routine Vision - Exam Only |
Cobertura Fuera de la Red:
Beneficio: | |
---|---|
Servicios/Suministros médicos | If you receive care from an out-of-network provider, your out-of-pocket costs will usually be higher than if you use a network provider. There are three exceptions: emergency care, urgently needed care and dialysis services. For details about the plan's coverage of out-of-network care, please refer to the Summary of Benefits or the Evidence of Coverage. (See "Plan Documents" below.) |
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) | |
Constancia de Cobertura (PDF) | |
Calificación del plan (PDF) | |
Formulario completo (PDF) | |
Mapa de áreas de servicio | |
Notificación Anual de Cambios | |
Formulario de Inscripción | |
Notificación general de transición (PDF) | |
Tabla de resumen de subsidios para la prima por bajos ingresos para quienes reciben ayuda adicional (PDF) |
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