FHCP Medicare Rx Savings (HMO) 2025

$20 copay

$50 copay

$500 copay per day for days 1-4
$0 copay per day for days 5-90
$0 copay per day for days 91 and beyond

$100 copay, waived if admitted within 24 hours for the same condition.

$20 - $50 copay, depending on the service

$395
(applies to Tiers 3, 4, & 5)

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): $10 copay
Standard Retail (31-Day): $20 copay
Standard Mail Order (93-Day): $27 copay

Tier 3 - Preferred Brand
Preferred Retail (31-Day): $45 copay
Standard Retail (31-Day): $47 copay
Standard Mail Order (93-Day): $132 copay

Tier 4 - Non-Preferred Drug
Preferred Retail (31-Day): $98 copay
Standard Retail (31-Day): $100 copay
Standard Mail Order (93-Day): $291 copay

Tier 5 - Specialty Tier
Preferred Retail (31-Day): 25% coinsurance
Standard Retail (31-Day): 25% 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

You pay 25% of the cost for brand name drugs (plus a portion of the dispensing fee) and 25% of the cost for generic drugs.

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
Health Education
Nutrition Classes
Preferred Fitness Program
Telemedicine
Nurse Advice Line

If you receive care from an out-of network provider without prior authorization from our plan, the care will not be covered except for emergency care, urgently needed care and dialysis services.

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.