Cobertura inicial:
tooltip_Until yearly drug costs reach $3,310, you'll pay..._2021
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..._2021
Cobertura catastrófica
tooltip_After your out-of-pocket costs plus the amount of the drug manufacturer's discounts reach $4,850, you'll pay…_2021
Cobertura para Medicinas Recetadas
| Deducible para medicinas recetadas |
$405 (applies to tiers 3, 4, 5) |
| Cobertura de medicinas recetadas dentro de la red - Cobertura inicial |
Tier 1 - Preferred Generics
|
| Brecha en la Cobertura |
You pay no more than 25% of the costs for preferred generic, generic and generic specialty drugs. You pay no more than 25% of the costs for brand name drugs and non-generic specialty drugs in the coverage gap. |
| Cobertura catastrófica |
You pay the greater of $3.70 or 5% for generic drugs and drugs treated like generics. You pay the greater of $9.20 or 5% for brand name drugs. |
Cobertura Fuera de la Red:
| Medicinas recetadas | This plan does not cover drugs filled at an out-of-network pharmacy. |
Documentos del plan
| Resumen de beneficios (PDF) | |
| Constancia de Cobertura (PDF) | |
| Calificación del plan (PDF) | |
| Notificación general de transición (PDF) | |
| Tabla de resumen de subsidios para la prima por bajos ingresos para quienes reciben ayuda adicional (PDF) | |
| Formulario completo (PDF) | |
| Notificación Anual de Cambios | |
| Mapa de áreas de servicio | |
| Formulario de inscripción |