PlanWell Benefits

• $86 monthly plan premium (Part D: $55.70 / Part C: $30.30)

• $250 Part D deductible (Drugs in Tier 1 and Tier 2 are excluded from the deductible

• Medicare Prescription Drug Coverage (Part D)

Tier 1–$0 copay, Tier 2–$10 copay, Tier 3–$47 copay, Tier 4–$100 copay, Tier 5–28% coinsurance

$15 copay Primary Care visits

• $35 copay Specialist visits

• $25 copay Physical Therapy

• $0 annual eye exam Our plan pays up to $250 every year for eyeglasses

•Optional $16 Dental monthly premium—Preventive & Comprehensive Services (No cap)

•$0 for annual hearing exam. Our plan pays up to $3,000 every 3 years for hearing aids

• Save money with a 90-day supply
T1-$0, T2-$15 T3-$117.50, T4- $250, T5-28% coinsurance

•Coverage Through the Gap
Tier 1: $0 for pharmacy & mail order

•$10 copay Acupuncture – 10 treatments per year

•$20 copay Chiropractor

•SilverSneakers Wellness/Fitness Program

•Rewards & Incentive Program

•PlanWell Navigator to help you access all your health benefits

For more  information about covered services associated and cost-sharing (e.g., copayments, coinsurance and deductibles) including any conditions and limitations please refer to the 2019 PlanWell Summary of Benefits

This plan uses a formulary. Limitations may apply.