Plan Summary - Complete
|
Complete powered by CCRx
Available in Charleston, West Virginia; Billings, Montana; Williamsport, Pennsylvania; Portland, Maine; Milwaukee/Green Bay, Wisconsin
Recommended for those who qualify for assistance from Medicaid. |
Complete powered by CCRx
Available in York/Erie, Pennsylvania; Omaha, Nebraska;
Indianapolis, Indiana
Recommended for those who qualify for assistance from Medicaid. |
 |
Network
 |
Out-of-Network
 |
Network
 |
Out-of-Network
 |
Monthly Premium |
$0- $22 |
$0- $22 |
$0 - $20.70 |
$0 - $20.70 |
MEDICAL BENEFITS |
Annual Out-of-Pocket Limit |
$3,000 |
$500 yearly deductible. Contact the plan for services that apply. |
N/A |
N/A |
PCP/Specialist Co-pay |
$0/$25 |
$35/$35 |
20% coinsurance/20% coinsurance |
20% coinsurance/20% coinsurance |
Inpatient Hospital Care |
• Days 1-5: $250 co-pay
• Days 6-90: $0 co-pay |
$800 co-pay for each hospital stay |
• Days 1-60: $1,068 deductible
• Days 61-90: $267/day
• Days 91-150: $534/lifetime reserve day |
Emergency Care |
$50 co-pay |
$25,000 limit for emergency services outside the U.S. every year. |
20% of the cost (up to $50) for Medicare-covered emergency room visits |
PART D PRESCRIPTION DRUG COVERAGE |
Deductible |
$295 yearly |
$295 yearly |
Initial Drug Coverage |
After deductible, you pay 25% until yearly costs reach $2,700. |
After deductible, reimbursement up to 75% drug cost purchased out-of-network until yearly costs reach $2,700. |
After deductible, you pay 25% until yearly costs reach $2,700. |
After deductible, reimbursement up to 75% drug cost purchased out-of-network until yearly costs reach $2,700. |
|
30-day/90-day supply, you pay |
30-day/90-day supply, you pay |
Generics |
25% coinsurance |
25% coinsurance |
25% coinsurance |
25% coinsurance |
Preferred Brands |
25% coinsurance |
25% coinsurance |
25% coinsurance |
25% coinsurance |
Non-preferred Brands |
No Coverage |
25% coinsurance |
25% coinsurance |
25% coinsurance |
Specialty Drugs |
25% coinsurance |
25% coinsurance |
25% coinsurance |
25% coinsurance |
Coverage Gap |
After $2,700, you pay 100% until yearly out-of-pocket costs reach $4,350. |
After $2,700, you pay 100% of drugs purchased out-of network until yearly out-of-pocket costs reach $4,350. |
After $2,700, you pay 100% until yearly out-of-pocket costs reach $4,350. |
After $2,700, you pay 100% of the drugs purchased out of network until out-of-pocket costs reach $4,350. |
Catastrophic Coverage after you reach $4,350 in out-of-pocket prescription drug expenses |
Generics |
The greater of 5% coinsurance or $2.40 |
The greater of 5% coinsurance or $2.40 (including brand drugs treated as generic) |
The greater of 5% coinsurance or $2.40 |
The greater of 5% coinsurance or $2.40 |
Brands |
The greater of 5% coinsurance or $6 |
The greater of 5% coinsurance or $6 |
The greater of 5% coinsurance or $6 |
The greater of 5% coinsurance or $6 |