** Cost ** |
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services |
$26 per month. In addition you must keep paying your Medicare Part B premium. |
This plan does not have a deductible. |
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. |
In this plan you may pay nothing for some services depending on your level of [insert State Medicaid plan name] eligibility. |
Your yearly limit(s) in this plan: |
- $1 000 for services you receive from in-network providers.
|
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. |
Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. |
** Doctor and Hospital Choice ** |
Acupuncture and Other Alternative Therapies |
Not covered |
** Extra Benefits ** |
Inpatient Mental Health Care |
For inpatient mental health care see the "Mental Health Care" section. |
Outpatient Prescription Drugs |
For Part B drugs such as chemotherapy drugs: $0 or $0-45 copay depending on the drug |
Other Part B drugs: $0 or $0-45 copay depending on the drug |
Our plan does not have a deductible for Part D prescription drugs. |
You pay the following:
|
You may get your drugs at network retail pharmacies and mail order pharmacies. |
Preferred Retail Cost-SharingTier | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 2 (Non-Preferred Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 3 (Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 4 (Non-Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 5 (Specialty Tier) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 6 (Vaccines) | $0 | Not Offered |
|
Standard Retail Cost-SharingTier | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 2 (Non-Preferred Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 3 (Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 4 (Non-Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 5 (Specialty Tier) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 6 (Vaccines) | $0 | Not Offered |
|
Preferred Mail Order Cost-SharingTier | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| $0 | Tier 2 (Non-Preferred Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 3 (Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 4 (Non-Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 5 (Specialty Tier) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
|
|
Standard Mail Order Cost-SharingTier | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 2 (Non-Preferred Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 3 (Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 4 (Non-Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 5 (Specialty Tier) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
|
|
If you reside in a long-term care facility you pay the same as at a retail pharmacy.
|
You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy.
|
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 700 you pay nothing for all drugs. |
** Important Information ** |
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services |
$26 per month. In addition you must keep paying your Medicare Part B premium. |
This plan does not have a deductible. |
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. |
In this plan you may pay nothing for some services depending on your level of [insert State Medicaid plan name] eligibility. |
Your yearly limit(s) in this plan: |
- $1 000 for services you receive from in-network providers.
|
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. |
Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. |
** Outpatient Care and Services ** |
Acupuncture and Other Alternative Therapies |
Not covered |
Ambulance Services |
$0 or $40 copay |
Chiropractic Care |
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $0 or $3 copay |
Dental Services |
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): $0 or $3 copay |
Diabetes Supplies and Services |
Diabetes monitoring supplies: You pay nothing |
Diabetes self-management training: You pay nothing |
Therapeutic shoes or inserts: You pay nothing |
Diagnostic Tests, Lab and Radiology Services, and X-Rays |
Diagnostic radiology services (such as MRIs CT scans): $0 or $3 copay |
Diagnostic tests and procedures: $0 or $0-3 copay depending on the service |
Lab services: $0 or $0-3 copay depending on the service |
Outpatient x-rays: $0 or $0-3 copay depending on the service |
Therapeutic radiology services (such as radiation treatment for cancer): $0 or $3 copay |
Doctor’s Office Visits |
Primary care physician visit: You pay nothing |
Specialist visit: $0 or $3 copay |
Durable Medical Equipment (wheelchairs, oxygen, etc.) |
You pay nothing |
Emergency Care |
$0 or $35 copay |
If you are immediately admitted to the hospital you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section for other costs. |
Foot Care (podiatry services) |
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $0 or $3 copay |
Hearing Services |
Exam to diagnose and treat hearing and balance issues: $0 or $3 copay |
Routine hearing exam: You pay nothing |
Home Health Care |
You pay nothing |
Mental Health Care |
Inpatient visit: |
Our plan covers an unlimited number of days for an inpatient hospital stay. |
|
$0 or $12 copay per stay |
You pay nothing per day for days 91 and beyond |
|
Outpatient group therapy visit: You pay nothing |
Outpatient individual therapy visit: $0 or $3 copay |
Outpatient Rehabilitation Services |
Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $0 or $3 copay |
Occupational therapy visit: $0 or $3 copay |
Physical therapy and speech and language therapy visit: $0 or $3 copay |
Outpatient Substance Abuse |
Group therapy visit: $0 or $3 copay |
Individual therapy visit: $0 or $3 copay |
Outpatient Surgery |
Ambulatory surgical center: $0 or $3 copay |
Outpatient hospital: $0 or $3 copay |
Over-the-Counter Items |
Not Covered |
Prosthetic Devices (braces, artificial limbs, etc.) |
Prosthetic devices: You pay nothing |
Related medical supplies: You pay nothing |
Renal Dialysis |
You pay nothing |
Transportation |
Not covered |
Urgently Needed Care |
$0 or $3-35 copay depending on the service |
Vision Services |
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0 or $3 copay |
Routine eye exam (for up to 1 every year): $3 copay |
Contact lenses (for up to 1 every two years): You pay nothing |
Eyeglasses (frames and lenses) (for up to 1 every two years): You pay nothing |
Eyeglasses or contact lenses after cataract surgery: You pay nothing |
Our plan pays up to $75 every two years for contact lenses and eyeglasses (frames and lenses). |
** Hospice ** |
Hospice |
You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. |
** Preventive Care ** |
Preventive Care |
You pay nothing |
Our plan covers many preventive services including: - Abdominal aortic aneurysm screening
- Alcohol misuse counseling
- Bone mass measurement
- Breast cancer screening (mammogram)
- Cardiovascular disease (behavioral therapy)
- Cardiovascular screenings
- Cervical and vaginal cancer screening
- Colonoscopy
- Colorectal cancer screenings
- Depression screening
- Diabetes screenings
- Fecal occult blood test
- Flexible sigmoidoscopy
- HIV screening
- Medical nutrition therapy services
- Obesity screening and counseling
- Prostate cancer screenings (PSA)
- Sexually transmitted infections screening and counseling
- Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
- Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
- "Welcome to Medicare" preventive visit (one-time)
- Yearly "Wellness" visit
Any additional preventive services approved by Medicare during the contract year will be covered. |
Annual physical exam: You pay nothing |
** Inpatient Care ** |
Inpatient Hospital Care |
Our plan covers an unlimited number of days for an inpatient hospital stay. |
|
$0 or $12 copay per stay |
You pay nothing per day for days 91 and beyond |
|
Inpatient Mental Health Care |
For inpatient mental health care see the "Mental Health Care" section. |
Skilled Nursing Facility (SNF) |
Our plan covers up to 100 days in a SNF. |
You pay nothing |
Outpatient Prescription Drugs |
For Part B drugs such as chemotherapy drugs: $0 or $0-45 copay depending on the drug |
Other Part B drugs: $0 or $0-45 copay depending on the drug |
Our plan does not have a deductible for Part D prescription drugs. |
You pay the following:
|
You may get your drugs at network retail pharmacies and mail order pharmacies. |
Preferred Retail Cost-SharingTier | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 2 (Non-Preferred Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 3 (Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 4 (Non-Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 5 (Specialty Tier) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 6 (Vaccines) | $0 | Not Offered |
|
Standard Retail Cost-SharingTier | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 2 (Non-Preferred Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 3 (Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 4 (Non-Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 5 (Specialty Tier) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 6 (Vaccines) | $0 | Not Offered |
|
Preferred Mail Order Cost-SharingTier | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| $0 | Tier 2 (Non-Preferred Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 3 (Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 4 (Non-Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 5 (Specialty Tier) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
|
|
Standard Mail Order Cost-SharingTier | One-month supply | Three-month supply |
---|
Tier 1 (Preferred Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 2 (Non-Preferred Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 3 (Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 4 (Non-Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| Tier 5 (Specialty Tier) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.65 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $6.60 copay.
|
|
If you reside in a long-term care facility you pay the same as at a retail pharmacy.
|
You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy.
|
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 700 you pay nothing for all drugs. |
** Outpatient Care ** |
Diabetes Supplies and Services |
Diabetes monitoring supplies: You pay nothing |
Diabetes self-management training: You pay nothing |
Therapeutic shoes or inserts: You pay nothing |
Foot Care (podiatry services) |
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $0 or $3 copay |
Hearing Services |
Exam to diagnose and treat hearing and balance issues: $0 or $3 copay |
Routine hearing exam: You pay nothing |
** Outpatient Medical Services and Supplies ** |
Outpatient Substance Abuse |
Group therapy visit: $0 or $3 copay |
Individual therapy visit: $0 or $3 copay |
Prosthetic Devices (braces, artificial limbs, etc.) |
Prosthetic devices: You pay nothing |
Related medical supplies: You pay nothing |
** Additional Benefits ** |
Inpatient Mental Health Care |
For inpatient mental health care see the "Mental Health Care" section. |