FHCP Medicare Rx Plus POS (HMO-POS) 2025

In-Network: $0 copay
Out-of-Network: $40 copay

In-Network: $20 copay
Out-of-Network: $40 copay

In-Network:
$300 copay per day for days 1-6
$0 copay per day for days 7-90
$0 copay per day for days 91 and beyond

Out-of-Network:
$300 copay per day for days 1-6
$0 copay per day beginning on day 7

In- and Out-of-Network
$100 copay, waived if admitted within 24 hours for the same condition.

In- and Out-of-Network
$0 - $20 copay, depending on the service

$0

Tier 1 - Preferred Generic
Preferred Retail (31-Day): $0 copay
Standard Retail (31-Day): $17 copay
Standard Mail Order (93-Day): $0 copay

Tier 2 - Generic
Preferred Retail (31-Day): $0 copay
Standard Retail (31-Day): $20 copay
Standard Mail Order (93-Day): $0 copay

Tier 3 - Preferred Brand
Preferred Retail (31-Day): $42 copay
Standard Retail (31-Day): $47 copay
Standard Mail Order (93-Day): $123 copay

Tier 4 - Non-Preferred Drug
Preferred Retail (31-Day): $92 copay
Standard Retail (31-Day): $100 copay
Standard Mail Order (93-Day): $273 copay

Tier 5 - Specialty Tier
Preferred Retail (31-Day): 33% coinsurance
Standard Retail (31-Day): 33% coinsurance
Standard Mail Order (93-Day): Not offered

Tier 6 - Vaccines ($0 Cost Sharing)
Preferred Retail (31-Day): $0 copay
Standard Retail (31-Day): $0 copay
Standard Mail Order (93-Day): Not offered

For Generic drugs, you pay:

Tier 1 - Preferred Generic
Preferred Retail (31-Day): $0 copay
Standard Retail (31-Day): $17 copay
Standard Mail Order (93-Day): $0 copay

Tier 2 - Generic
Preferred Retail (31-Day): $0 copay
Standard Retail (31-Day): $20 copay
Standard Mail Order (93-Day): $0 copay

OR
25% of the cost, whichever is less.

For brand name drugs, you pay 25% of the cost (plus a portion of the dispensing fee).

Tier 6 - Vaccines ($0 Cost Sharing)
Preferred Retail (31-Day): $0 copay
Standard Retail (31-Day): $0 copay
Standard Mail Order (93-Day): Not offered

$0 Copay

Routine Vision
Routine Hearing Exam
Hearing Aid Fitting/Evaluation
Hearing Aids
Preventive Dental
Comprehensive Dental
Health Education
Nutrition Classes
Preferred Fitness Program
Telemedicine
Nurse Advice Line

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.)

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). 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.