X hits on this document

PDF document

Providence Health Plan is a health plan with a Medicare contract. - page 17 / 32

81 views

0 shares

0 downloads

0 comments

17 / 32

SUMMARY OF BENEFITS

If you have any questions about this plan’s benefits or costs, please contact Providence Health Plan.

Benefit Category

Original Medicare

Providence Medicare Extra + RX

29 - Prescription Drugs (continued)

If you request a formulary exception for a drug and Providence Medicare Extra + RX approves the exception, you will pay Tier 3: Specialty Tier Drugs cost sharing for that drug.

In-Network $0 deductible.

Initial Coverage You pay the following until total yearly drug costs reach $2,840:

Retail Pharmacy Tier 1: Generic Drugs

$6 copay for a one-month (30-day) supply of drugs in this tier from a preferred pharmacy.

$18 copay for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy.

$9 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred pharmacy.

$27 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy.

17

Document info
Document views81
Page views81
Page last viewedSat Dec 10 09:45:05 UTC 2016
Pages32
Paragraphs574
Words8210

Comments