PPO II - EmblemHealth

2013 Evidence of Coverage for PPO II) II
SECTION Chapter 6: 3 What you benefi pay ts for are your not covered Part D prescription by the plan? drugs
SECTION 7 DURING THE CATASTROPHIC COVERAGE STAGE, THE
PLAN PAYS MOST OF THE COST FOR YOUR DRUGS
Section 7.1 Once you are in the Catastrophic Coverage Stage,
you will stay in this stage for the rest of the year
You qualify for the Catastrophic Coverage Stage when your out-of-pocket costs have reached the $4,750
limit for the calendar year. Once you are in the Catastrophic Coverage Stage, you will stay in this
payment stage until the end of the calendar year.
During this stage, the plan will pay most of the cost for your drugs.
• Your share of the cost for a covered drug will be either coinsurance or a copayment, whichever is
the larger amount:
� –either – coinsurance of 5% of the cost of the drug
� –or – $2.65 copayment for a generic drug or a drug that is treated like a generic. Or a
$6.60 copayment for all other drugs.
• Our plan pays the rest of the cost.
SECTION 8 WHAT YOU PAY FOR VACCINATIONS COVERED
BY PART D DEPENDS ON HOW AND WHERE
YOU GET THEM
Section 8.1 Our plan has separate coverage for the Part D vaccine
medication itself and for the cost of giving you the
vaccination shot
Our plan provides coverage of a number of Part D vaccines. We also cover vaccines that are considered
medical benefi ts. You can fi nd out about coverage of these vaccines by going to the Medical Benefi ts
Chart in Chapter 4, Section 2.1.
Th ere are two parts to our coverage of Part D vaccinations:
• Th e fi rst part of coverage is the cost of the vaccine medication itself. Th e vaccine is a
prescription medication.
• Th e second part of coverage is for the cost of giving you the vaccination shot. (Th is is
sometimes called the “administration” of the vaccine.)
What do you pay for a Part D vaccination?
What you pay for a Part D vaccination depends on three things:
1. Th e type of vaccine (what you are being vaccinated for).
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