X hits on this document

PDF document

Providence Health Plan is a health plan with a Medicare contract. - page 18 / 32

103 views

0 shares

0 downloads

0 comments

18 / 32

SUMMARY OF BENEFITS

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

Benefit Category

29 - Prescription Drugs (continued)

Original Medicare

Providence Medicare Extra + RX Tier 2: Brand Drugs

$45 copay for a one-month (30-day) supply of drugs in this tier from a preferred pharmacy. $135 copay for a three-month (90-day) supply of drugs in this tier from a preferred pharmacy. $45 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred pharmacy. $135 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred pharmacy.

Tier 3: Specialty Tier Drugs

33% coinsurance for a one- month (30-day) supply of drugs in this tier from a preferred pharmacy. 33% coinsurance for a one- month (30-day) supply of drugs in this tier from a non-preferred pharmacy.

Long Term Care Pharmacy

Tier 1: Generic Drugs $9 copay for a one-month (34-day) supply of drugs in this tier.

Tier 2: Brand Drugs

$45 copay for a one-month (34-day) supply of drugs in this tier.

Tier 3: Specialty Tier Drugs

33% coinsurance for a one- month (34-day) supply of drugs in this tier.

18

Document info
Document views103
Page views103
Page last viewedFri Jan 20 00:11:34 UTC 2017
Pages32
Paragraphs574
Words8210

Comments