Cobertura inicial:
tooltip_Until yearly drug costs reach $3,310, you'll pay..._2024
Brecha de la cobertura
tooltip_After costs paid by you and the drug plan are greater than $3,310 and your out-of-pocket is less than $4,850, you'll pay..._2024
Cobertura catastrófica
tooltip_After your out-of-pocket costs plus the amount of the drug manufacturer's discounts reach $4,850, you'll pay…_2024
Cobertura para Medicinas Recetadas
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Deducible para medicinas recetadas El monto que debe pagar antes de que nuestro plan comience a pagar la parte correspondiente de su cobertura para medicinas. |
$0 |
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Cobertura de medicinas recetadas dentro de la red - Cobertura inicial Durante la Etapa de Cobertura Inicial, el plan paga un porcentaje del costo de sus medicinas y usted paga el porcentaje del costo en base al nivel de la medicina. Se queda en esta etapa hasta que los costos totales de la medicina (sus pagos y cualquier pago del plan) alcance el Límite de Cobertura Inicial (Initial Coverage Limit, ICL). Una vez que alcance el ICL, será transferido a la Etapa de Brecha en la Cobertura. |
Tier 1 - Preferred Generics
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Brecha en la Cobertura Durante el período sin cobertura es posible que pague más por sus medicinas que lo que pagó en la etapa de cobertura inicial. Por eso se le llama "Brecha". Permanece en la brecha de cobertura hasta que los costos totales a su cargo por medicinas alcancen el Límite de Cobertura Inicial. |
This plan has coverage in the Part D coverage gap. Tier 1 (preferred generic drugs) and Tier 2 (generic drugs) 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 network retail pharmacy. You pay no more than $10 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. |
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Cobertura catastrófica Una vez que llegue a la etapa catastrófica, pagara $0 durante el resto del año. |
$0 copay |
Cobertura Fuera de la Red:
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Medicinas recetadas Medicinas recetadas |
Normally, we 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 3 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.) |
Documentos del plan
| Resumen de beneficios (PDF) |
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| Constancia de Cobertura (PDF) |
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| Calificación del plan (PDF) |
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| Notificación general de transición (PDF) |
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| Tabla de resumen de subsidios para la prima por bajos ingresos para quienes reciben ayuda adicional (PDF) |
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| Formulario completo de BlueMedicare Rx (PDF) |
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| Notificación Anual de Cambios |
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| Formulario de inscripción |
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