| Coverage Summary | |
|---|---|
| Primary Care Doctor Visit | $0 copay |
| Specialist Visit | $40 copay |
| Inpatient Hospital Care | $205 copay per day for days 1-6 |
| Emergency Services (In and out-of-network) | $90 copay; ER copay waived if admitted |
| Urgent Care Services | $45 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): $10 copay Standard Retail (31-day supply): $15 copay Preferred Retail (90-day supply): $30 copay Standard Retail (90-day supply): $45 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): 33% 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 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 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. (See ''Plan Documents'' below.) |
| 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 | $5 copay |
| Inpatient Hospital Care | $0 copay |
| 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): $11 copay Preferred Retail (90-day supply): $0 copay Standard Retail (90-day supply): $33 copay Mail Order (90-day supply): $0 copay Tier 3 - Preferred Brands Preferred Retail (31-day supply): $20 copay Standard Retail (31-day supply): $45 copay Preferred Retail (90-day supply): $60 copay Standard Retail (90-day supply): $135 copay Mail Order (90-day supply): $60 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) : 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 | |