| “This tool provides useful information to
help you review plans
based on your current drug needs. The drug costs displayed are
estimates and may vary based on the specific quantity, strength
and/or dosage of the medication, the order in which you purchase
your prescriptions, and the pharmacy you use. But it also is
important to look beyond your current needs at the insurance
value of Medicare prescription drug coverage. Enrolling now
gives you peace of mind because the coverage will be there even
if your drug needs become more significant in the future. And
any time you spend out-of-pocket more than $4,050 in a year,
Medicare will pay almost all of your remaining drug costs.” |
| Medical
Coverage for OSF Care Preferred Rx |
| Benefit |
You Pay: |
Doctor's Office
Visit(s) |
- $10 for each primary care doctor office
visit for Medicare-covered services.
- 20%-30% for each out-of-network primary
care doctor office visit. (1)
- $15 for each specialist visit for
Medicare-covered services.
- 20% for each out-of-network specialist
visit. (1)
|
| Inpatient Hospitalization |
- $150 for each Medicare-covered stay at a
network hospital.
- $1000 for each stay at an out-of-network
hospital.
- No copayment for additional days received
at a network hospital.
|
| Outpatient Services |
- No copayment for each Medicare-covered
visit to an ambulatory surgical center or outpatient hospital
facility.
- 20%-30% of the cost of services at an
out-of-network ambulatory surgical center or outpatient hospital
facility. (1)
|
| Emergency Care |
- $50 for each Medicare-covered emergency
room visit. You do not pay this amount if you are admitted to the
hospital within 24 hours for the same condition.
- Worldwide coverage.
|
| Outpatient Rehab/Therapy |
- No copayment for each Medicare-covered
Occupational, Physical and/or Speech/Language Therapy visit.
- 20%-30% of the cost for out-of-network
Occupational, Physical and/or Speech/Language Therapy visit.
(1)
|
| Urgently Needed Care |
- $10 for each Medicare-covered urgently
needed care visit.
- $10 to $50 for out-of-network urgent care
services.
- Worldwide coverage.
|
* Authorization rules may apply for services.
Contact plan for more details.
(1) You pay a $110 yearly deductible for the following
Medicare-covered plan services when received out-of-network.
This is not a complete benefit listing; please
see our Summary of Benefits for a complete benefit summary. If you
have questions, please call Member Services at 309-677-8203, toll
free 1-877-677-8203 or for the hearing and speech impaired (TTY)
888-817-0139. Our business office hours are Monday through Friday
8am to 5pm. Our business phone hours are 24 hours a day, 365 days a
year.
|
Medicare Part D Pharmacy
Coverage
OSF Care Preferred (PPO) Rx
| |
|
| Monthly Premium: |
$125 (Medical & Medicare Part D Pharmacy
combined) |
| |
No deductible |
|
| Up
to $2,510 in drug cost: |
This is not a
complete benefit listing.
Please click here
for a complete benefit summary. |
| Preferred generic |
$9 copayment |
| Preferred brand |
$36 copayment |
| Non-Preferred |
50% coinsurance |
| Specialty |
30% coinsurance |
|
From $2,511 in total drug cost until you've paid $4,050 in TrOOP |
| Preferred generic |
$16 copayment |
| All other covered |
60% coinsurance |
|
After $4,050 annual TrOOP cost: |
| Preferred |
Greater of $2.25 or 5% |
| Non-Preferred |
Greater of $5.60 or 5% |
TrOOP = True out-of-pocket
TrOOP is the amount the beneficiary must spend on Part D-covered drugs
to reach the catastrophic cap.
* You must continue to pay the Medicare Part B premium.
You may be able to get extra help to pay for your prescription drug
premiums and costs. To see if you qualify for getting extra help,
call:
- 1-800-MEDICARE (1-800-633-4227). TTY/TDD
users should call 1-877-486-2048, 24 hours a day/7 days a week);
- The Social Security Administration at
1-800-772-1213 between 7 am and 7 pm, Monday through Friday. TTY/TDD users should call,
1-800-325-0778; or
- Your State Medicaid Office.
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