![]() ![]() Inpatient Hospital Care $100 per stay No Coverage $90 copay per visit ($0 copay when outside of the United States)Īmbulance Services $65 copay for ground or air $65 copay for ground or air $0 copay for at least 3-month supply of Tier 1 medications with Preferred Mail Home Delivery from OptumRx.Īmbulatory Surgical Center 2 $0 copay $500 copayĭiabetes Monitoring Supplies 2 $0 copay No coverageĭiagnostic Radiology Services (such as MRIs/CT scans, etc.)ĭiagnostic Radiology Services (such as MRIs/CT scans, etc.) $0 copay $200 copayĭiagnostic Tests and Procedures, non-radiological (such as EKG/ECG tests, etc.)ĭiagnostic Tests and Procedures, non-radiological (such as EKG/ECG tests, etc.) $0 copay $40 copayĮmergency Care $90 copay per visit ($0 copay when outside of the United States) $90 copay per visit ($0 copay when outside of the United States) Preferred Mail Home Delivery through OptumRx The money you spend using your card counts toward your out-of-pocket costs.Īfter your total out-of-pocket costs reach $7,400, you will pay the greater of $4.15 copay for generic (including brand drugs treated as generic), and $10.35 copay for all other drugs, or 5% coinsurance. Always use your Medicare Advantage member ID card during the coverage gap to get the plan's discounted drug rates. ![]() You may pay less if your plan has additional coverage in the gap. x Close Popupĭuring the Coverage Gap Stage, you (or others on your behalf) will pay no more than 25% of the price for generic drugs or 25% of the price (plus the dispensing fee) for brand name drugs, for any drug tier until the total amount you (or others on your behalf) have paid reaches $7,400 in year-to-date out-of-pocket costs. For all other plans: You will pay a maximum of $35 for each 1-month supply of Part D covered insulin drug through all coverage stages.
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