Coverage Summary
| Benefit: | You Pay: |
|---|---|
|
Primary Care Doctor Visit
The Primary Care Doctor you choose will focus on your needs and coordinate your care with other network providers. |
$0 de copago |
|
Specialist Visit
Care you receive from a doctor who specializes in a certain type of medicine. Certain specialists do not require a Primary Care Doctor referral. Ask your Primary Care Doctor if you need a referral. |
$15 de copago |
|
Inpatient Hospital Care
Prior Authorization is required for non-emergency Inpatient Hospital stays. |
$215 de copago por día por los días 1 al 5 |
|
Emergency Services (In and out-of-network)
Services received at a hospital facility's Emergency department, including both Professional and Facility services. |
$125 de copago, no aplica si es admitido dentro de las 24 horas por la misma afección. |
|
Urgent Care Services
Urgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury or condition that requires immediate medical attention. |
$0 - $10 de copago, dependiendo del servicio |
Prescription Drug Coverage
| Benefit: | You Pay: |
|---|---|
|
Prescription Drug Deductible
The amount you must pay before our plan begins to pay its share of your covered drugs. |
$0 |
|
In-Network Prescription Drug Coverage - Initial Coverage
During the initial coverage stage, your plan helps cover the costs of your prescription drugs. How much you pay depends on which plan you have, what tier your prescription is in, and where and how you fill your prescription. Check your plan’s Evidence of Coverage for more details about what you pay. |
Nivel 1 - Genéricas preferidas |
|
Coverage Gap
In the coverage gap, you may pay more for your drugs than you did in the initial coverage stage. That’s why it’s called a “gap”. You stay in the coverage gap until your total out-of-pocket drug costs reach the Initial Coverage Limit. |
Para medicinas genéricas, usted paga: |
|
Catastrophic Coverage
Once you reach the Catastrophic Stage, you pay a small copay and the plan will pay most of the cost of your drugs for the rest of the year. |
$0 de copago |
Extra Coverage
| Benefit: | |
|---|---|
|
Extra Benefits
Enjoy some of these extra benefits included in your plan |
Servicios de rutina para la vista |
Out of Network Coverage
| Benefit: | |
|---|---|
|
Medical Services/Supplies
Medical Services/Supplies |
Si recibe servicios de un proveedor fuera de la red sin autorización previa de nuestro plan, la atención no estará cubierta excepto para servicios de emergencia, de atención necesaria de urgencia o de diálisis. |
|
Prescription Drugs
Prescription Drugs |
Por lo general, cubrimos las medicinas que se obtienen en una farmacia fuera de la red solo si no puede usar nuestra red de farmacias (por ejemplo, porque está viajando, en caso de emergencia o cuidado de urgencia). El Capítulo 5 de su Constancia de cobertura incluye una lista completa de situaciones en las cuales podríamos cubrir medicinas 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 |
|
| Find a Doctor, Hospital, and Pharmacy | |
| Request for PHI Form | |
| Transition of Care | |
| Enrollment Form |
|