Benefits are determined by the provider’s Tier level.
Our goal is to minimize administrative costs, invest in the benefits that matter most to our members, deliver exceptional service, and become a leading regional MAPD health plan.
| Benefits/Services | Tier 1 | Tier 2 | Tier 3 |
|---|---|---|---|
| Maximum Out-of-Pocket (MOOP) | $3,850 | $3,850 | $3,850 |
| Premium | $0 | $0 | $0 |
| Part B Giveback | $50 | $50 | $50 |
| Inpatient Hospital/ACUTE | $0 Copay per stay | $295 Copay, per day, Days 1-6 | $2,185 Copay per stay |
| Emergency | $110 Copay | $110 Copay | $110 Copay |
| Primary Care | $0 Copay | $0 Copay | $20 Copay |
| Chiropractic | $15 Copay | $15 Copay | $15 Copay |
| Specialist | $0 Copay | $35 Copay | $35 Copay |
| Outpatient Diagnostic Procedures/Tests | $0 Copay | $50 Copay | $95 Copay |
| X-Rays | $0 Copay | $15 Copay | 20% Coinsurance |
| Outpatient Blood Services | $0 Copay | $0 Copay | 35% Coinsurance |
| Over-The-Counter (OTC) Allowance | $40 Quarterly Benefit Allowance | $40 Quarterly Benefit Allowance | $40 Quarterly Benefit Allowance |
| Meals | 14 meals following discharge from the hospital | 14 meals following discharge from the hospital | 14 meals following discharge from the hospital |
| Monthly Fitness Reimbursement | $50 | $50 | $50 |
Additional benefits include:
| Pharmacy Tiers | Preferred Retail and Mail Cost-Sharing (In-Network) (up to a 30-day supply) | Preferred Retail and Mail Cost-Sharing (In-Network) (up to a 100-day supply) | Standard Retail and Mail Cost-Sharing (In-Network) (up to a 30-day supply) | Standard Retail and Mail Cost-Sharing (In-Network) (up to a 100-day supply) |
|---|---|---|---|---|
| Cost-Sharing Tier 1 (preferred generic) | $0 Copay | $0 Copay | $0 Copay | $0 Copay |
| Cost-Sharing Tier 2 (generic) | $0 Copay | $0 Copay | $10 Copay | $30 Copay |
| Cost-Sharing Tier 3 (preferred brand) | $0 Copay | $0 Copay | $47 Copay | $141 Copay |
| Cost-Sharing Tier 4 (non-preferred drug) | $0 Copay | $0 Copay | $100 Copay | $300 Copay |
| Cost-Sharing Tier 5 (specialty) | 33% Coinsurance | N/A | 33% Coinsurance | N/A |
Additional benefits include:
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