Essential Coverage PPO
|Benefit||Essential Coverage PPO|
|Primary Care Copay||In $10 | Out $35|
|Specialist Copay||In $50 | Out $70|
|Preferred Pharmacy Initial Coverage (tiered coverage 1/2/3/4/5/6)||$0 | $15 | $42 | $95 | 33% | $0|
|Standard Pharmacy Initial Coverage (tiered coverage 1/2/3/4/5/6)||$15 | $20 | $47 | $100 | 33% | $5|
|Coverage Gap Coverage||Tiers 1 and 6|
|Monthly Dental Premium (Optional)||$33.30|
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.