Enhanced Coverage PPO
|Benefit||Enhanced Coverage PPO|
|Primary Care Copay||In $5 | Out $25|
|Specialist Copay||In $40 | Out $60|
|Preferred Pharmacy Initial Coverage (tiered coverage 1/2/3/4/5/6)||$0 | $10 | $35 | $90 | 33% | $0|
|Standard Pharmacy Initial Coverage (tiered coverage 1/2/3/4/5/6)||$10 | $15 | $40 | $95 | 33% | $5|
|Coverage Gap Coverage||Tiers 1, 2 and 6|
|Monthly Dental Premium (Optional)||$28.00|
For more details, please review theSummary of Benefits
When you receive care covered by your benefit plan from a provider outside of our network, you are only responsible for paying your share of the cost, not the entire cost. Under this out-of-network coverage rule, your share of the cost may be higher for an out-of-network provider than for an in-network provider.
This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.
You must continue to pay your Medicare Part B premium.