$40 copay per visit always covered when you need itĮye Exam 3 $0 copay 1 per year 30% of the cost combined visits In and Out of Networkģ0% of the cost combined visits In and Out of Network Urgent Care $40 copay per visit always covered when you need it $40 copay per visit always covered when you need it Skilled Nursing Facility $0 copay per day: Days 1-100 30% of the cost $0 copay - 30% of the cost (depending on the service) Preventive Services (such as covered screenings, vaccinations, etc.) 2 $0 copay for covered services $0 copay - 30% of the cost (depending on the service) Preventive Services (such as covered screenings, vaccinations, etc.) Outpatient X-rays $0 copay 30% of the cost
Outpatient Hospital Services (includes observation services) 2 $0 copay - 20% of the cost 30% of the cost Outpatient Hospital Services (includes observation services) Opioid Treatment Services $0 copay $0 copay Mental Health (outpatient) Group: 20% of the cost Inpatient Hospital Care $1,556 per stay $1,556 per stay Home Health Care $0 copay 30% of the cost $90 copay per visit always covered when you need itĪmbulance Services 20% of the cost for ground or air 20% of the cost for ground or air You may pay less if your plan has additional coverage in the gap.Īfter your total out-of-pocket costs reach $7,400, you will pay the greater of $4.15 copay for generic (including brand drugs treated as generic), and $10.35 copay for all other drugs, or 5% coinsurance.Īmbulatory Surgical Center 2 $0 copay - 20% of the cost 30% of the costĭiabetes Monitoring Supplies 2 20% of the cost 30% of the costĭiagnostic Radiology Services (such as MRIs/CT scans, etc.)ĭiagnostic Radiology Services (such as MRIs/CT scans, etc.) 0% of the cost - 20% of the cost 30% of the costĭiagnostic Tests and Procedures, non-radiological (such as EKG/ECG tests, etc.)ĭiagnostic Tests and Procedures, non-radiological (such as EKG/ECG tests, etc.) 20% of the cost 30% of the costĮmergency Care $90 copay per visit always covered when you need it $90 copay per visit always covered when you need it $0, $1.45, $4.15 copay, or 15% of the total costĪll Other Drugs $0, $4.30, $10.35 copay, or 15% of the total costĭuring the Coverage Gap Stage, you (or others on your behalf) will pay no more than 25% of the price for generic drugs or 25% of the price (plus the dispensing fee) for brand name drugs, for any drug tier until the total amount you (or others on your behalf) have paid reaches $7,400 in year-to-date out-of-pocket costs. Generic (including brand drugs treated as generic) Initial Coverage Stage - If you qualify for LIS (Extra Help)
For all other plans: You will pay a maximum of $35 for each 1-month supply of Part D covered insulin drug through all coverage stages. For Chronic Special Needs plans: You will pay a maximum of $25 for each 1-month supply of Part D select insulin drug through all coverage stages.
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