| Coverage Summary | |
|---|---|
|
Primary Care Doctor Visit
The Primary Care Doctor you choose will focus on your needs and coordinate your care with other network providers. |
$0 copay in-network |
|
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. |
Level 1 $35 Copayment in-network Level 2 (All Other) $44 Copayment in-network |
|
Inpatient Hospital Care
Prior Authorization is required for non-emergency Inpatient Hospital stays. |
$290 copay per day for days 1-6 in-network |
|
Emergency Services (In and out-of-network)
Services received at a hospital facility's Emergency department, including both Professional and Facility services. |
$120 copay; ER copay waived if admitted |
|
Urgent Care Services
Urgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury or condition that requires immediate medical attention. |
$50 copay in and out-of-network |
| Prescription Drug Coverage | |
|---|---|
|
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. |
Tier 1 - Preferred Generics Standard Retail (31-day supply): $2 copay Standard Retail (100-day supply):$6 copay Mail Order (100-day supply): $6 copay Tier 2 - Generics Standard Retail (31-day supply): $10 copay Standard Retail (100-day supply): $30 copay Mail Order (100-day supply): $30 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): 33% of the costs Tier 6 - Select Care Drugs All Locations (31-day supply): $0 copay All Locations (100-day supply): $0 copay |
|
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. |
This plan has coverage in the Part D coverage gap. 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 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
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 copay |
| Extra Coverage | |
|---|---|
|
Extra Benefits
Enjoy some of these extra benefits included in your plan |
Routine Dental Routine Vision Routine Hearing SilverSneakers Fitness Program Telehealth Services Caregiver Support Over- the-Counter |
| Out of Network Coverage | |
|---|---|
|
Medical Services/Supplies
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
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) | |
| Annual Notice of Change | |
| Enrollment Form | |
| Coverage Summary | |
|---|---|
|
Primary Care Doctor Visit
The Primary Care Doctor you choose will focus on your needs and coordinate your care with other network providers. |
$0 copay |
|
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. |
$0 copay |
|
Inpatient Hospital Care
Prior Authorization is required for non-emergency Inpatient Hospital stays. |
$0 copay |
|
Emergency Services (In and out-of-network)
Services received at a hospital facility's Emergency department, including both Professional and Facility services. |
$135 copay; ER copay waived if admitted |
|
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 copay in and out-of-network |
| Prescription Drug Coverage | |
|---|---|
|
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. |
Tier 1 - Preferred Generics Standard Retail (31-day supply): $0 copay Standard Retail (100-day supply):$0 copay Mail Order (100-day supply): $0 copay Tier 2 - Generics Standard Retail (31-day supply): $0 copay Standard Retail (100-day supply): $0 copay Mail Order (100-day supply): $0 copay Tier 3 - Preferred Brands Standard Retail (31-day supply): $0 copay Standard Retail (90-day supply): $0 copay Mail Order (90-day supply): $0 copay Tier 4 - Non-Preferred Drugs Standard Retail (31-day supply): $50 copay Standard Retail (90-day supply): $150 copay Mail Order (90-day supply): $150 copay Tier 5 - Specialty Drugs All Locations (31-day supply): 33% of the costs |
|
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. |
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 network retail pharmacy. You pay no more than $0 for Tier 2 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
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 copay |
| Extra Coverage | |
|---|---|
|
Extra Benefits
Enjoy some of these extra benefits included in your plan |
Routine Dental Routine Hearing Routine Vision SilverSneakers Fitness Program Routine Transportation Over-the-Counter Items Allowance Telehealth Services Caregiver Support |
| Out of Network Coverage | |
|---|---|
|
Medical Services/Supplies
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
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) | |
| Annual Notice of Change | |
| Enrollment Form | |