2016 Medicare Advantage Plan Details |
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Medicare Plan Name: | NetworkCares (PPO SNP) |
Location: | Green Lake, Wisconsin Click to see other locations |
Plan ID: | H5215 - 007 - 0 Click to see other plans |
Member Services: | 1-800-378-5234 TTY users 1-800-947-3529 |
— This plan information is for research purposes only. — Click here to see plans for the current plan year |
Medicare Contact Information: | Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options. TTY users 1-877-486-2048 or contact your local SHIP for assistance |
Email a copy of the NetworkCares (PPO SNP) benefit details
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— Medicare Plan Features — |
Monthly Premium: | $0.00 for people who qualify for both Medicare and Medicaid. (see Plan Premium Details below) |
Annual Deductible: | $0 for people who qualify for both Medicare and Medicaid. |
Annual Initial Coverage Limit (ICL): | $3,310 |
Health Plan Type: | Local PPO |
Special Needs Plan (SNP) Eligibility Requirement: | Dual-Eligible |
Additional Gap Coverage? | No additional gap coverage, only the Donut Hole Discount |
Total Number of Formulary Drugs: | 5,990 drugs | Browse the NetworkCares (PPO SNP) Formulary |
This plan has 5 drug tiers.
See cost-sharing for all pharmacies and tiers.
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Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $1.00 | $13.00 | $42.00 | $80.00 | 30% |
• Number of Drugs per Tier: | 55 | 2420 | 490 | 2188 | 837 |
Plan's Pharmacy Search: | http://www.NetworkHealthMedicare.com |
Plan Offers Mail Order? | Yes |
Number of Members enrolled in this plan in Green Lake, Wisconsin: | 83 members |
Number of Members enrolled in this plan in Wisconsin: | 2,804 members |
Number of Members enrolled in this plan in (H5215 - 007): | 2,809 members |
Plan’s Summary Star Rating: | 4.5 out of 5 Stars. |
• Customer Service Rating: | 4 out of 5 Stars. |
• Member Experience Rating: | 5 out of 5 Stars. |
• Drug Cost Accuracy Rating: | 4 out of 5 Stars. |
— Plan Premium Details — |
The Monthly Premium is Split as Follows: ❔ | Total Premium | Part C Premium | Part D Base Premium | Part D Supplemental Premium |
$37.70 | $0.00 | $37.70 | $0.00 |
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy |
Monthly Part D Premium with LIS: | $0.00 | $9.40 | $18.80 | $28.30 |
Total Monthly Premium with LIS (Parts C & D): | $0.00 | $9.40 | $18.80 | $28.30 |
— Plan Health Benefits — |
** Cost ** |
Monthly premium, deductible, and limits on how much you pay for covered services |
$37.7 per month. In addition you must keep paying your Medicare Part B premium. |
This plan has deductibles for some hospital and medical services. |
$0 to $74 per year for Part D prescription drugs. |
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: |
- $6 700 for services you receive from in-network providers.
|
- $10 000 for services you receive from any provider. Your limit for services received from in-network providers will count toward this limit.
|
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 benefits from any provider. Contact us for services that apply. |
** Doctor and Hospital Choice ** |
Acupuncture |
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 drugs1:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Other Part B drugs1:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
You pay the following:
|
You may get your drugs at network retail pharmacies and mail order pharmacies. |
Standard Retail Cost-Sharing Tier | One-month supply | Three-month supply |
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Tier 1 (Preferred Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 2 (Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 3 (Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 4 (Non-Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 5 (Specialty Tier) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Not Offered | |
Preferred Retail Cost-Sharing Tier | One-month supply | Three-month supply |
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Tier 1 (Preferred Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 2 (Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 3 (Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 4 (Non-Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 5 (Specialty Tier) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Not Offered | |
Standard Mail Order Cost-Sharing Tier | One-month supply | Three-month supply |
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Tier 1 (Preferred Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 2 (Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 3 (Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 4 (Non-Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 5 (Specialty Tier) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Not Offered | |
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 but may pay more than you pay at an in-network pharmacy.
|
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 850 you pay nothing for all drugs. |
** Important Information ** |
Monthly premium, deductible, and limits on how much you pay for covered services |
$37.7 per month. In addition you must keep paying your Medicare Part B premium. |
This plan has deductibles for some hospital and medical services. |
$0 to $74 per year for Part D prescription drugs. |
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: |
- $6 700 for services you receive from in-network providers.
|
- $10 000 for services you receive from any provider. Your limit for services received from in-network providers will count toward this limit.
|
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 benefits from any provider. Contact us for services that apply. |
** Outpatient Care and Services ** |
Acupuncture |
Not covered |
Ambulance |
- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Chiropractic care |
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Dental services |
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Preventive dental services: |
Cleaning (for up to 1 every six months):- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Dental x-ray(s) (for up to 2):- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Oral exam (for up to 1 every six months):- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Our plan pays up to $1 500 every year for most dental services from any provider. |
Diabetes supplies and services |
Diabetes monitoring supplies:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Diabetes self-management training:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Therapeutic shoes or inserts:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Diagnostic tests, lab and radiology services, and x-rays (Costs for these services may be different if received in an outpatient surgery setting) |
Diagnostic radiology services (such as MRIs CT scans):- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Diagnostic tests and procedures:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Lab services:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Outpatient x-rays:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Therapeutic radiology services (such as radiation treatment for cancer):- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Doctor's office visits |
Primary care physician visit:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Specialist visit:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Durable medical equipment (wheelchairs, oxygen, etc.) |
- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Emergency care |
0% or 20% of the cost (up to $75) |
If you are admitted to the hospital within 24 hours 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:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Hearing services |
Exam to diagnose and treat hearing and balance issues:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Home health care |
- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Mental health care |
Inpatient visit: |
Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. |
The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. |
Our plan covers 90 days for an inpatient hospital stay. |
Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days you can use these extra days. But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days. |
Outpatient group therapy visit:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Outpatient individual therapy visit:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Outpatient rehabilitation |
Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks):- In-network: 0% or 20% of the cost . Additional visits are covered but your cost may be more.
|
- Out-of-network: Additional visits are covered but your cost may be more.
|
- Out-of-network: 20% of the cost
|
Occupational therapy visit:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Physical therapy and speech and language therapy visit:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Outpatient substance abuse |
Group therapy visit:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Individual therapy visit:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Outpatient surgery |
Ambulatory surgical center:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Outpatient hospital:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Over-the-counter items |
Please visit our website to see our list of covered over-the-counter items. |
Prosthetic devices (braces, artificial limbs, etc.) |
Prosthetic devices:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Related medical supplies:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Renal dialysis |
- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Transportation |
Not covered |
Urgently needed services |
0% or 20% of the cost (up to $65) |
Vision services |
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Routine eye exam (for up to 1 every year):- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Contact lenses (for up to 12 every year):- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Eyeglasses (frames and lenses) (for up to 1 every year):- In-network: You pay nothing
|
- Out-of-network: You pay nothing
|
Eyeglasses or contact lenses after cataract surgery:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Our plan pays up to $425 every year for contact lenses and eyeglasses (frames and lenses) from any provider. |
** 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 |
- In-network: You pay nothing
|
- Out-of-network: 20% of the cost
|
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
- Colorectal cancer screenings (Colonoscopy Fecal occult blood test Flexible sigmoidoscopy)
- Depression screening
- Diabetes screenings
- 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:- In-network: You pay nothing
|
** Inpatient Care ** |
Inpatient hospital care |
The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. |
Our plan covers 90 days for an inpatient hospital stay. |
Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days you can use these extra days. But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days. |
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. |
Outpatient prescription drugs |
For Part B drugs such as chemotherapy drugs1:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Other Part B drugs1:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
You pay the following:
|
You may get your drugs at network retail pharmacies and mail order pharmacies. |
Standard Retail Cost-Sharing Tier | 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
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 2 (Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 3 (Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 4 (Non-Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 5 (Specialty Tier) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Not Offered | |
Preferred Retail Cost-Sharing Tier | 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
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 2 (Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 3 (Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 4 (Non-Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 5 (Specialty Tier) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Not Offered | |
Standard Mail Order Cost-Sharing Tier | 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
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 2 (Generic) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 3 (Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 4 (Non-Preferred Brand) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Tier 5 (Specialty Tier) | For generic drugs (including brand drugs treated as generic) either:- $0 copay; or
- $1.20 copay; or
- $2.95 copay
For all other drugs either:- $0 copay; or
- $3.60 copay; or
- $7.40 copay.
| Not Offered | |
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 but may pay more than you pay at an in-network pharmacy.
|
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 850 you pay nothing for all drugs. |
** Outpatient Care ** |
Diabetes supplies and services |
Diabetes monitoring supplies:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Diabetes self-management training:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Therapeutic shoes or inserts:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Foot care (podiatry services) |
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Hearing services |
Exam to diagnose and treat hearing and balance issues:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
** Outpatient Medical Services and Supplies ** |
Outpatient substance abuse |
Group therapy visit:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Individual therapy visit:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Prosthetic devices (braces, artificial limbs, etc.) |
Prosthetic devices:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
Related medical supplies:- In-network: 0% or 20% of the cost
|
- Out-of-network: 20% of the cost
|
** Additional Benefits ** |
Inpatient mental health care |
For inpatient mental health care see the "Mental Health Care" section. |