| Coverage Summary | |
|---|---|
| Primary Care Doctor Visit |
Level 1 $0 Copayment in-network Level 2 (All Other) $10 Copayment in-network |
| Specialist Visit |
Level 1 $30 Copayment in-network Level 2 (All Other) $43 Copayment in-network |
| Inpatient Hospital Care | $295 copay per day for days 1-5 in-network |
| Emergency Services (In and out-of-network) | $90 copay; ER copay waived if admitted |
| Urgent Care Services | $40 copay in and out-of-network |
| Prescription Drug Coverage | |
|---|---|
| Prescription Drug Deductible | $150 (applies to Tiers 3,4,5 only) |
| In-Network Prescription Drug Coverage - Initial Coverage |
Tier 1 - Preferred Generics Standard Retail (31-day supply): $0 copay Standard Retail (90-day supply): $0 copay Mail Order (90-day supply): $0 copay Tier 2 - Generics Standard Retail (31-day supply): $8 copay Standard Retail (90-day supply):$24 copay Mail Order (90-day supply): $24 copay Tier 3 - Preferred Brands Standard Retail (31-day supply): $47 copay Standard Retail (90-day supply): $141 copay Mail Order (90-day supply): $141 copay Tier 4 - Non-Preferred Drugs Standard Retail (31-day supply): $100 copay Standard Retail (90-day supply): $300 copay Mail Order (90-day supply): $300 copay Tier 5 - Specialty Drugs All Locations (31-day supply): 30% of the costs Tier 6 - Select Care Drugs All Locations (31-day supply): $0 copay All Locations (90-day supply): $0 copay |
| Coverage Gap | 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 network retail pharmacy. You pay no more than $0 for Tier 6 medications at a network retail 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. |
| Catastrophic Coverage | You pay the greater of $3.95 or 5% for generic drugs and drugs treated like generics. You pay the greater of $9.85 or 5% for brand name drugs. |
| Extra Coverage | |
|---|---|
| Extra Benefits |
Routine Dental Routine Vision Routine Hearing SilverSneakers Fitness Program Telehealth Services At Home Care Caregiver Support Over-the-Counter Health Education |
| Out of Network Coverage | |
|---|---|
| Medical Services/Supplies | 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.) |
| Prescription Drugs | 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. |
| 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) | |
| Service Area Map | |
| Annual Notice of Change | |
| Enrollment Forms | |
| Coverage Summary | |
|---|---|
| Primary Care Doctor Visit | $5 copay in-network |
| Specialist Visit | $45 copay in-network |
| Inpatient Hospital Care | $225 copay per day for days 1-7 in-network |
| Emergency Services (In and out-of-network) | $90 copay; ER copay waived if admitted |
| Urgent Care Services | $25 copay in and out-of-network |
| Prescription Drug Coverage | |
|---|---|
| Prescription Drug Deductible | $305 (applies to Tiers 1, 2, 3, 4, 5) |
| In-Network Prescription Drug Coverage - Initial Coverage |
Tier 1 - Preferred Generics
Preferred Retail (31-day supply): $3 copay Standard Retail (31-day supply) : $13 copay Preferred Retail (90-day supply): $9 copay Standard Retail (90-day supply): $39 copay Mail Order (90-day supply): $9 copay Tier 2 - Generics Preferred Retail (31-day supply): $10 copay Standard Retail (31-day supply) : $20 copay Preferred Retail (90-day supply): $30 copay Standard Retail (90-day supply): $60 copay Mail Order (90-day supply): $30 copay Tier 3 - Preferred Brands Preferred Retail (31-day supply): $40 copay Standard Retail (31-day supply): $47 copay Preferred Retail (90-day supply): $120 copay Standard Retail (90-day supply): $141 copay Mail Order (90-day supply): $120 copay Tier 4 - Non-Preferred Drugs Preferred Retail (31-day supply): $93 copay Standard Retail (31-day supply): $100 copay Preferred Retail (90-day supply): $279 copay Standard Retail (90-day supply): $300 copay Mail Order (90-day supply):$279 copay Tier 5 - Specialty Drugs All Locations (31-day supply): 28% of the costs Tier 6 - Select Care Drugs All Locations (31-day supply): $0 copay All Locations (90-day supply): $0 copay |
| Coverage Gap | 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 $3 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. |
| Catastrophic Coverage | You pay the greater of $3.95 or 5% for generic drugs and drugs treated like generics. You pay the greater of $9.85 or 5% for brand name drugs. |
| Extra Coverage | |
|---|---|
| Extra Benefits |
Routine Dental
Routine Hearing Routine Vision SilverSneakers Fitness Program Telehealth Services At Home Care Health Education Caregiver Support |
| Out of Network Coverage | |
|---|---|
| Medical Services/Supplies | 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.) |
| Prescription Drugs | 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. |
| 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) | |
| Service Area Map | |
| Annual Notice of Change | |
| Enrollment Forms | |
| Coverage Summary | |
|---|---|
| Primary Care Doctor Visit | $0 copay |
| Specialist Visit | $10 copay |
| Inpatient Hospital Care | $125 copay per day for days 1-6 |
| Emergency Services (In and out-of-network) | $115 copay; ER copay waived if admitted |
| Urgent Care Services | $10 copay in and out-of-network |
| Prescription Drug Coverage | |
|---|---|
| Prescription Drug Deductible | $0 |
| In-Network Prescription Drug Coverage - Initial Coverage |
Tier 1 - Preferred Generics Preferred Retail (31-day supply): $0 copay Standard Retail (31-day supply): $10 copay Preferred Retail (90-day supply): $0 copay Standard Retail (90-day supply): $30 copay Mail Order (90-day supply): $0 copay Tier 2 - Generics Preferred Retail (31-day supply): $0 copay Standard Retail (31-day supply): $15 copay Preferred Retail (90-day supply): $0 copay Standard Retail (90-day supply): $45 copay Mail Order (90-day supply): $0 copay Tier 3 - Preferred Brands Preferred Retail (31-day supply): $30 copay Standard Retail (31-day supply): $47 copay Preferred Retail (90-day supply): $90 copay Standard Retail (90-day supply): $141 copay Mail Order (90-day supply): $90 copay Tier 4 - Non-Preferred Drugs Preferred Retail (31-day supply): $90 copay Standard Retail (31-day supply): $100 copay Preferred Retail (90-day supply): $270 copay Standard Retail (90-day supply): $300 copay Mail Order (90-day supply): $270 copay Tier 5 - Specialty Drugs All Locations (31-day supply): 33% of the costs |
| Coverage Gap | This plan has coverage in the Part D coverage gap. Tier 1 (preferred generic drugs) and Tier 2 (generics) 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 2 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. |
| Catastrophic Coverage | You pay the greater of $3.95 or 5% for generic drugs and drugs treated like generics. You pay the greater of $9.85 or 5% for brand name drugs. |
| Extra Coverage | |
|---|---|
| Extra Benefits |
Routine Dental Routine Vision Routine Hearing SilverSneakers Fitness Program Routine Transportation Over-the-Counter Items Allowance Telehealth Services At Home Care Caregiver Support Health Education |
| Out of Network Coverage | |
|---|---|
| Medical Services/Supplies | 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. |
| Prescription Drugs | 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. |
| 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) | |
| Service Area Map | |
| Annual Notice of Change | |
| Enrollment Forms | |