14
SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS
The benefit information provided is a summary of what we cover and what you pay. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the “Evidence of Coverage.” You can also see the Evidence of Coverage on our website, www.paramounthealthcare.com/medicareplans.
Sections in this booklet • Things to Know About Paramount Elite - Enhanced Medical & Drug (HMO), Paramount Elite - Standard
Medical & Drug (HMO) and Paramount Elite - Prime Medical & Drug (HMO)
• Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
• Covered Medical and Hospital Benefits
• Prescription Drug Benefits
This document is available in other formats such as Braille and large print. This document may be available in a non-English language. For additional information, call us at 1-800-462-3589 (TTY: (888)740-5670).
Things to Know About Paramount Elite - Enhanced Medical & Drug (HMO), Paramount Elite - Standard Medical & Drug (HMO) and Paramount Elite - Prime Medical & Drug (HMO) Hours of Operation & Contact Information
• From October 1 to March 31 we’re open 8 a.m. – 8 p.m. local time, 7 days a week. • From April 1 to September 30, we’re open 8 a.m. – 8 p.m. local time, Monday through Friday. • Call us at 1-800-462-3589, TTY: (888)740-5670.
• Our website: www.paramounthealthcare.com/medicareplans.
Who can join?
To join Paramount Elite - Enhanced Medical & Drug (HMO), Paramount Elite - Standard Medical & Drug (HMO) and Paramount Elite - Prime Medical & Drug (HMO) you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and must live in our service area. Our service area includes these counties in Michigan: Hillsdale, Lenawee and Monroe. Our service area includes these counties in Ohio: Allen, Cuyahoga, Defiance, Erie, Fulton, Hardin, Henry, Huron, Lake, Lorain, Lucas, Medina, Ottawa, Paulding, Putnam, Sandusky, Summit, Williams and Wood.
What do we cover?
Like all Medicare health plans, we cover everything that Original Medicare covers – and more. Some of the extra benefits are outlined in this booklet. We cover Part D drugs. In addition, we cover Part B drugs including chemotherapy and some drugs administered by your provider.
• You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, www.paramounthealthcare.com/medicareplans.
• Or, call us and we will send you a copy of the formulary.
SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS
Which doctors, hospitals, and pharmacies can I use?
Paramount Elite - Enhanced Medical & Drug (HMO), Paramount Elite - Standard Medical & Drug (HMO) and Paramount Elite - Prime Medical & Drug (HMO) have a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services.
You must also generally use network pharmacies to fill your prescriptions for covered Part D drugs.
You can see our plan’s Provider Directory and Pharmacy Directory at our website, http://www.paramounthealthcare.com/medicareplans.
Or, call us and we will send you a copy of the Provider and Pharmacy Directories. How will I determine my drug costs? Our plan groups each medication into one of five "tiers." You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. The amount you pay depends on the drug's tier and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur: Initial Coverage, Coverage Gap and Catastrophic Coverage.
If you want to know more about the coverage and costs of Original Medicare, look in your current Medicare & You Handbook. View it online at http://www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
If you have any questions about this plan's benefits or costs, please contact Paramount Elite/Medicare Plans
SECTION II - SUMMARY OF BENEFITS
TT Paramount Elite - Enhanced Medical & Drug (HMO)
Paramount Elite - Standard Medical & Drug (HMO)
Paramount Elite - Prime Medical & Drug (HMO)
MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES
Monthly Plan Premium
$69 per month. In addition, you must keep paying your Medicare Part B premiums.
$0 per month. In addition, you must keep paying your Medicare Part B premiums.
$28 per month. In addition, you must keep paying your Medicare Part B premiums.
Deductible Medical Deductible: Not Applicable. Prescription Drugs Deductible: Not Applicable.
Medical Deductible: Not Applicable. Prescription Drugs Deductible: Not Applicable.
Medical Deductible: Not Applicable. Prescription Drugs Deductible: Not Applicable.
Maximum Out-of-Pocket Responsibility
Your yearly limit(s) in this plan: • $3,400 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.
Your yearly limit(s) in this plan: • $4,900 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 cost-sharing for your Part D prescription drugs.
Your yearly limit(s) in this plan: • $4,400 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.
SECTION II - SUMMARY OF BENEFITS
TT Paramount Elite - Enhanced Medical & Drug (HMO)
Paramount Elite - Standard Medical & Drug (HMO)
Paramount Elite - Prime Medical & Drug (HMO)
COVERED MEDICAL AND HOSPITAL BENEFITS
Inpatient Hospital
In-Network: Days 1-5: $200 Copay per day. $0 Copay per day for each additional day.
May require prior authorization.
There is no limit to the number of days covered by the plan each hospital stay.
In-Network: Days 1-5: $300 Copay per day. $0 Copay per day for each additional day.
May require prior authorization.
There is no limit to the number of days covered by the plan each hospital stay.
In-Network: Days 1-5: $225 Copay per day. $0 Copay per day for each additional day.
May require prior authorization.
There is no limit to the number of days covered by the plan each hospital stay.
Ambulatory Surgical Center
In-Network: Ambulatory Surgical Center: $200 Copay.
May require prior authorization.
In-Network: Ambulatory Surgical Center: $340 Copay.
May require prior authorization.
In-Network: Ambulatory Surgical Center: $225 Copay.
May require prior authorization.
Outpatient Hospital
In-Network:
Outpatient Hospital Surgery: $200 Copay.
May require prior authorization.
In-Network:
Outpatient Hospital Surgery: $340 Copay.
May require prior authorization.
In-Network:
Outpatient Hospital Surgery: $225 Copay.
May require prior authorization.
Doctor's Office Visits
In-Network: Primary care physician visit: $0 Copay.
Specialist visit: $40 Copay.
In-Network: Primary care physician visit: $10 Copay.
Specialist visit: $40 Copay.
In-Network: Primary care physician visit: $0 Copay.
Specialist visit: $35 Copay.
Preventive Care (e.g., flu vaccine, diabetic screenings)
In-Network: You pay nothing for all preventive services covered under Original Medicare at zero cost sharing.
Any additional preventive services approved by Medicare during the contract year will be covered.
In-Network: You pay nothing for all preventive services covered under Original Medicare at zero cost sharing.
Any additional preventive services approved by Medicare during the contract year will be covered.
In-Network: You pay nothing for all preventive services covered under Original Medicare at zero cost sharing.
Any additional preventive services approved by Medicare during the contract year will be covered.
SECTION II - SUMMARY OF BENEFITS
TT Paramount Elite - Enhanced Medical & Drug (HMO)
Paramount Elite - Standard Medical & Drug (HMO)
Paramount Elite - Prime Medical & Drug (HMO)
Emergency Care
$120 Copay per visit.
If you are admitted to the same hospital within 1 day for the same diagnosis, you do not have to pay your share of the cost for emergency care.
$90 Copay per visit.
If you are admitted to the same hospital within 1 day for the same diagnosis, you do not have to pay your share of the cost for emergency care.
$90 Copay per visit.
If you are admitted to the same hospital within 1 day for the same diagnosis, you do not have to pay your share of the cost for emergency care.
Urgently Needed Services
$45 Copay per visit. $45 Copay per visit. $40 Copay per visit.
Worldwide Coverage
$0 Copay up to combined maximum $25,000 limit for Emergency Care, Urgently Needed Services, and Emergency Transportation outside of the United States.
$0 Copay up to combined maximum $25,000 limit for Emergency Care, Urgently Needed Services, and Emergency Transportation outside of the United States.
$0 Copay up to combined maximum $25,000 limit for Emergency Care, Urgently Needed Services, and Emergency Transportation outside of the United States.
Diagnostic Services / Labs/ Imaging
In-Network:
Diagnostic tests and procedures: $10 Copay.
Lab services: $0 - $10 Copay.
Advanced Diagnostic Radiology (such as MRI, CAT Scan): $150 Copay.
X-rays: $10 Copay.
Therapeutic Radiology Services (such as radiation treatment for cancer): 20% Coinsurance
May require prior authorization.
In-Network:
Diagnostic tests and procedures: $20 Copay.
Lab services: $0 - $20 Copay.
Advanced Diagnostic Radiology (such as MRI, CAT Scan): $150 Copay.
X-rays: $20 Copay.
Therapeutic Radiology Services (such as radiation treatment for cancer): 20% Coinsurance
May require prior authorization.
In-Network:
Diagnostic tests and procedures: $15 Copay.
Lab services: $0 - $15 Copay.
Advanced Diagnostic Radiology (such as MRI, CAT Scan): $150 Copay.
X-rays: $15 Copay.
Therapeutic Radiology Services (such as radiation treatment for cancer): 20% Coinsurance
May require prior authorization.
Hearing Services
In-Network: Exam to diagnose and treat hearing and balance issues: $40 Copay.
Routine hearing exam (for up to 1 every year): $40 Copay.
In-Network: Exam to diagnose and treat hearing and balance issues: $40 Copay.
Routine hearing exam (for up to 1 every year): $40 Copay.
In-Network: Exam to diagnose and treat hearing and balance issues: $35 Copay.
Routine hearing exam (for up to 1 every year): $35 Copay.
SECTION II - SUMMARY OF BENEFITS
TT Paramount Elite - Enhanced Medical & Drug (HMO)
Paramount Elite - Standard Medical & Drug (HMO)
Paramount Elite - Prime Medical & Drug (HMO)
Hearing Aid Coverage
$699 - $999 Copay per HA (for up to 2 every year). Benefit provided by TruHearing.
Hearing Aid Coverage
$699 - $999 Copay per HA (for up to 2 every year). Benefit provided by TruHearing.
Hearing Aid Coverage
$699 - $999 Copay per HA (for up to 2 every year). Benefit provided by TruHearing.
Dental Services In-Network:
Medicare Covered: 0% Coinsurance.
Preventive dental services:
• Periodic Oral exam (for up to 2 every year): $0 Copay.
• Cleaning (for up to 2 every year): $0 Copay.
• Dental X-rays (for up to 4 bitewing every year): $0 Copay.
Must use Paramount Dental’s Medicare Advantage network for preventive dental services.
In-Network:
Medicare Covered: 0% Coinsurance.
Preventive dental services:
• Periodic Oral exam (for up to 2 every year): $0 Copay.
• Cleaning (for up to 2 every year): $0 Copay.
• Dental X-rays (for up to 4 bitewing every year): $0 Copay.
Must use Paramount Dental’s Medicare Advantage network for preventive dental services.
In-Network:
Medicare Covered: 0% Coinsurance.
Preventive dental services:
• Periodic Oral exam (for up to 2 every year): $0 Copay.
• Cleaning (for up to 2 every year): $0 Copay.
• Dental X-rays (for up to 4 bitewing every year): $0 Copay.
Must use Paramount Dental’s Medicare Advantage network for preventive dental services.
Optional Comprehensive Dental
Optional comprehensive dental benefit package available for an extra premium of $27.60 per month provided by Paramount Dental. Allowance: $25 deductible, then 30% coinsurance for comprehensive dental services up to $1,000 maximum coverage. New crowns are covered at 50% coinsurance after deductible.
Must use Paramount Dental’s Medicare Advantage network for optional comprehensive dental services.
Optional comprehensive dental benefit package available for an extra premium of $27.60 per month provided by Paramount Dental. Allowance: $25 deductible, then 30% coinsurance for comprehensive dental services up to $1,000 maximum coverage. New crowns are covered at 50% coinsurance after deductible.
Must use Paramount Dental’s Medicare Advantage network for optional comprehensive dental services.
Optional comprehensive dental benefit package available for an extra premium of $27.60 per month provided by Paramount Dental. Allowance: $25 deductible, then 30% coinsurance for comprehensive dental services up to $1,000 maximum coverage. New crowns are covered at 50% coinsurance after deductible.
Must use Paramount Dental’s Medicare Advantage network for optional comprehensive dental services.
SECTION II - SUMMARY OF BENEFITS
TT Paramount Elite - Enhanced Medical & Drug (HMO)
Paramount Elite - Standard Medical & Drug (HMO)
Paramount Elite - Prime Medical & Drug (HMO)
Vision Services In-Network: Exam to diagnose and treat diseases and conditions of the eye: $40 Copay.
Routine eye exam (for up to 1 every year): $0 Copay.
Preventive Glaucoma Screening: (for up to 1 every year): $0 Copay.
Preventive Diabetic Retinopathy Screening: (for up to 1 every year): $0 Copay.
Eyeglasses or contact lenses after cataract surgery: 20% Coinsurance.
Vision Hardware Benefit Contact lenses: $0 Copay up to $100 limit every 2 years.
Basic Eyeglass lenses: $0 Copay every 2 years.
Eyeglass frames: $0 Copay up to $75 limit every 2 years.
In-Network: Exam to diagnose and treat diseases and conditions of the eye: $40 Copay.
Routine eye exam (for up to 1 every year): $0 Copay.
Preventive Glaucoma Screening: (for up to 1 every year): $0 Copay.
Preventive Diabetic Retinopathy Screening: (for up to 1 every year): $0 Copay.
Eyeglasses or contact lenses after cataract surgery: 20% Coinsurance.
Vision Hardware Benefit Contact lenses: $0 Copay up to $100 limit every 2 years.
Basic Eyeglass lenses: $0 Copay every 2 years.
Eyeglass frames: $0 Copay up to $75 limit every 2 years.
In-Network: Exam to diagnose and treat diseases and conditions of the eye: $35 Copay.
Routine eye exam (for up to 1 every year): $0 Copay.
Preventive Glaucoma Screening: (for up to 1 every year): $0 Copay.
Preventive Diabetic Retinopathy Screening: (for up to 1 every year): $0 Copay.
Eyeglasses or contact lenses after cataract surgery: 20% Coinsurance.
Vision Hardware Benefit Contact lenses: $0 Copay up to $100 limit every 2 years.
Basic Eyeglass lenses: $0 Copay every 2 years.
Eyeglass frames: $0 Copay up to $75 limit every 2 years.
Mental Health Care
In-Network: Outpatient group therapy visit: $40 Copay.
Individual therapy visit: $40 Copay.
In-Network: Outpatient group therapy visit: $40 Copay.
Individual therapy visit: $40 Copay.
In-Network: Outpatient group therapy visit: $35 Copay.
Individual therapy visit: $35 Copay.
Skilled Nursing Facility (SNF)
In-Network: Days 1-9: $0 Copay per day. Days 10-20: $20 Copay per day. Days 21-100: $155 Copay per day. Our plan covers up to 100 days in a SNF. Requires prior authorization.
In-Network: Days 1-20: $0 Copay per day. Days 21-100: $160 Copay per day.
Our plan covers up to 100 days in a SNF.
Requires prior authorization.
In-Network: Days 1-20: $0 Copay per day. Days 21-100: $155 Copay per day.
Our plan covers up to 100 days in a SNF.
Requires prior authorization.
SECTION II - SUMMARY OF BENEFITS
TT Paramount Elite - Enhanced Medical & Drug (HMO)
Paramount Elite - Standard Medical & Drug (HMO)
Paramount Elite - Prime Medical & Drug (HMO)
Outpatient Rehabilitation
In-Network: Occupational therapy visit: $25 Copay.
Physical therapy and speech and language therapy visit: $25 Copay.
May require prior authorization.
In-Network: Occupational therapy visit: $40 Copay.
Physical therapy and speech and language therapy visit: $40 Copay.
May require prior authorization.
In-Network: Occupational therapy visit: $25 Copay.
Physical therapy and speech and language therapy visit: $25 Copay.
May require prior authorization.
Ambulance In-Network: Ground Ambulance: $150 Copay.
Air Ambulance: $150 Copay.
In-Network: Ground Ambulance: $340 Copay.
Air Ambulance: $340 Copay.
In-Network: Ground Ambulance: $200 Copay.
Air Ambulance: $200 Copay.
Transportation In-Network: Not Covered.
In-Network: Not Covered.
In-Network: Not Covered.
Medicare Part B Drugs
In-Network: For Part B drugs such as chemotherapy drugs: 20% Coinsurance.
Other Part B drugs: 20% Coinsurance.
May require prior authorization.
In-Network: For Part B drugs such as chemotherapy drugs: 20% Coinsurance.
Other Part B drugs: 20% Coinsurance.
May require prior authorization.
In-Network: For Part B drugs such as chemotherapy drugs: 20% Coinsurance.
Other Part B drugs: 20% Coinsurance.
May require prior authorization.
SECTION II - SUMMARY OF BENEFITS
TT Paramount Elite - Enhanced Medical & Drug (HMO)
Paramount Elite - Standard Medical & Drug (HMO)
Paramount Elite - Prime Medical & Drug (HMO)
PRESCRIPTION DRUG BENEFITS
Initial Coverage You pay the following until your total yearly drug costs reach $4,020. Total yearly drug costs are the drug costs paid by both you and our Part D plan.
Standard Retail Cost-Sharing
Tier One-month
supply
Tier 1 (Preferred Generic) $0 copay
Tier 2 (Generic) $15 copay
Tier 3 (Preferred Brand) $45 copay
Tier 4 (Non-Preferred Drug) $100 copay
Tier 5 (Specialty Tier)
33% coinsurance
Standard Retail Cost-Sharing
Tier Three-month
supply (up to 90-day)
Tier 1 (Preferred Generic) $0 copay
Tier 2 (Generic) $45 copay
You pay the following until your total yearly drug costs reach $4,020. Total yearly drug costs are the drug costs paid by both you and our Part D plan.
Standard Retail Cost-Sharing
Tier One-month
supply
Tier 1 (Preferred Generic) $0 copay
Tier 2 (Generic) $20 copay
Tier 3 (Preferred Brand) $45 copay
Tier 4 (Non-Preferred Drug) $100 copay
Tier 5 (Specialty Tier)
33% coinsurance
Standard Retail Cost-Sharing
Tier Three-month
supply (up to 90-day)
Tier 1 (Preferred Generic) $0 copay
Tier 2 (Generic) $60 copay
You pay the following until your total yearly drug costs reach $4,020. Total yearly drug costs are the drug costs paid by both you and our Part D plan.
Standard Retail Cost-Sharing
Tier One-month
supply
Tier 1 (Preferred Generic) $0 copay
Tier 2 (Generic) $10 copay
Tier 3 (Preferred Brand) $45 copay
Tier 4 (Non-Preferred Drug) $100 copay
Tier 5 (Specialty Tier)
33% coinsurance
Standard Retail Cost-Sharing
Tier Three-month
supply (up to 90-day)
Tier 1 (Preferred Generic) $0 copay
Tier 2 (Generic) $30 copay
SECTION II - SUMMARY OF BENEFITS
TT Paramount Elite - Enhanced Medical & Drug (HMO)
Paramount Elite - Standard Medical & Drug (HMO)
Paramount Elite - Prime Medical & Drug (HMO)
Tier 3 (Preferred Brand) $135 copay
Tier 4 (Non-Preferred Drug) $300 copay
Tier 5 (Specialty Tier) Not Applicable
Standard Mail Order
Tier One-month
supply
Tier 1 (Preferred Generic) $0 copay
Tier 2 (Generic) $15 copay
Tier 3 (Preferred Brand) $45 copay
Tier 4 (Non-Preferred Drug) $100 copay
Tier 5 (Specialty Tier) Not Applicable
Standard Mail Order
Tier Three-month
supply (up to 90-day)
Tier 1 (Preferred Generic) $0 copay
Tier 3 (Preferred Brand) $135 copay
Tier 4 (Non-Preferred Drug) $300 copay
Tier 5 (Specialty Tier) Not Applicable
Standard Mail Order
Tier One-month
supply
Tier 1 (Preferred Generic) $0 copay
Tier 2 (Generic) $20 copay
Tier 3 (Preferred Brand) $45 copay
Tier 4 (Non-Preferred Drug) $100 copay
Tier 5 (Specialty Tier) Not Applicable
Standard Mail Order
Tier Three-month
supply (up to 90-day)
Tier 1 (Preferred Generic) $0 copay
Tier 3 (Preferred Brand) $135 copay
Tier 4 (Non-Preferred Drug) $300 copay
Tier 5 (Specialty Tier) Not Applicable
Standard Mail Order
Tier One-month
supply
Tier 1 (Preferred Generic) $0 copay
Tier 2 (Generic) $10 copay
Tier 3 (Preferred Brand) $45 copay
Tier 4 (Non-Preferred Drug) $100 copay
Tier 5 (Specialty Tier) Not Applicable
Standard Mail Order
Tier Three-month
supply (up to 90-day)
Tier 1 (Preferred Generic) $0 copay
SECTION II - SUMMARY OF BENEFITS
TT Paramount Elite - Enhanced Medical & Drug (HMO)
Paramount Elite - Standard Medical & Drug (HMO)
Paramount Elite - Prime Medical & Drug (HMO)
Tier 2 (Generic) $30 copay
Tier 3 (Preferred Brand) $90 copay
Tier 4 (Non-Preferred Drug) $200 copay
Tier 5 (Specialty Tier) Not Applicable
Your cost-sharing may be different if you use an out-of-network pharmacy, Long Term Care pharmacy, or if you purchase a long-term supply (up to 90 days) of a mail order drug.
Please call us or see the plan’s “Evidence of Coverage” on our website (www.paramounthealthcare.com/medicareplans) for complete information about your costs for covered drugs.
Tier 2 (Generic) $40 copay
Tier 3 (Preferred Brand) $90 copay
Tier 4 (Non-Preferred Drug) $200 copay
Tier 5 (Specialty Tier) Not Applicable
Your cost-sharing may be different if you use an out-of-network pharmacy, Long Term Care pharmacy, or if you purchase a long-term supply (up to 90 days) of a mail order drug.
Please call us or see the plan’s “Evidence of Coverage” on our website (www.paramounthealthcare.com/medicareplans) for complete information about your costs for covered drugs.
Tier 2 (Generic) $20 copay
Tier 3 (Preferred Brand) $90 copay
Tier 4 (Non-Preferred Drug) $200 copay
Tier 5 (Specialty Tier) Not Applicable
Your cost-sharing may be different if you use an out-of-network pharmacy, Long Term Care pharmacy, or if you purchase a long-term supply (up to 90 days) of a mail order drug.
Please call us or see the plan’s “Evidence of Coverage” on our website (www.paramounthealthcare.com/medicareplans) for complete information about your costs for covered drugs.
Coverage Gap The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,020. After you enter the coverage gap, you pay 25% of the plan's cost for covered brand name drugs and 25% of the plan's cost for covered generic drugs until your costs total $6,350, which is the end of the coverage gap.
The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,020. After you enter the coverage gap, you pay 25% of the plan's cost for covered brand name drugs and 25% of the plan's cost for covered generic drugs until your costs total $6,350, which is the end of the coverage gap.
The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,020. After you enter the coverage gap, you pay 25% of the plan's cost for covered brand name drugs and 25% of the plan's cost for covered generic drugs until your costs total $6,350, which is the end of the coverage gap.
SECTION II - SUMMARY OF BENEFITS
TT Paramount Elite - Enhanced Medical & Drug (HMO)
Paramount Elite - Standard Medical & Drug (HMO)
Paramount Elite - Prime Medical & Drug (HMO)
Our plan covers Tier 1 Preferred Generics in the coverage gap.
Standard Retail Cost-Sharing
Tier One-month
supply
Tier 1 (Preferred Generic)
$0 copay
.
Our plan covers Tier 1 Preferred Generics in the coverage gap.
Standard Retail Cost-Sharing
Tier One-month
supply
Tier 1 (Preferred Generic)
$0 copay
.
Our plan covers Tier 1 Preferred Generics in the coverage gap.
Standard Retail Cost-Sharing
Tier One-month
supply
Tier 1 (Preferred Generic)
$0 copay
.
Catastrophic Amount
After your yearly out-of-pocket drug costs reach $6,350, you pay the greater of:
• $3.60 copay for generic (including brand drugs treated as generic) and a $8.95 copayment for all other drugs, or
• 5% of the cost.
After your yearly out-of-pocket drug costs reach $6,350, you pay the greater of:
• $3.60 copay for generic (including brand drugs treated as generic) and a $8.95 copayment for all other drugs, or
• 5% of the cost.
After your yearly out-of-pocket drug costs reach $6,350, you pay the greater of:
• $3.60 copay for generic (including brand drugs treated as generic) and a $8.95 copayment for all other drugs, or
• 5% of the cost.
Our Plans offer supplemental benefits in addition to Part C benefits and Part D benefits.
