Summary of Benefits Part D Prescription Drugs continued Premiums SummaCare Medicare and Benefits Topaz (HMO) SummaCare Medicare Topaz (HMO) Northeast
SummaCare Medicare Garnet 1 (HMO) SummaCare Medicare Garnet 1 (HMO) Northeast
SummaCare Medicare Ruby (HMO) Northeast SummaCare Medicare Ruby (HMO) Northeast
If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy. Coverage Gap Stage
Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $4,020. After you enter the coverage gap, you pay 25% of the plan’s cost for covered brand name drugs and 25% of the plan’s cost for covered generic drugs until your costs total $6,350, which is the end of the coverage gap. Not everyone will enter the coverage gap. Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug’s tier. See the chart that follows to find out how much it will cost you. All Tier 1 (Preferred Generic) drugs (retail and mail-order) are covered at a $0 copay if you enter the Coverage Gap. Tier 6 Vaccines are also covered at a $0 copay through the Coverage Gap.
Catastrophic Coverage Stage
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $6,350, you pay the greater of • 5% of the cost, or • $3.60 copay for generic (including brand drugs treated as generic) and a $8.95 copay for all other drugs
Additional Benefits: Acupuncture – Up to six combined visits per calendar year for general acupuncture services performed by in-network providers are covered. The visit limit is combined with the therapeutic massage benefit. Visits must be scheduled through SummaCare’s Acupuncture/ Therapeutic Massage vendor, Homelink.
$20 copay per visit for up to a maximum of six combined acupuncture and therapeutic massage service visits per calendar year.
$10 copay per visit for up to a maximum of six combined acupuncture and therapeutic massage service visits per calendar year.
Not covered
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