Summary of Benefits
The Summary of Benefits outlines your plan premium, benefits, copayments and coinsurance for the current calendar year.
Please click on the link below to find out about the plan benefits.
The Provider & Pharmacy Directory outlines your plan's network of Primary Care Physicians, Specialists, Hospitals, Skilled Nursing Facilities, Outpatient Facilities, Pharmacies and Supplemental Provider contacts.
Find a provider or pharmacy online here.
Download a copy here: 2021
You must receive your care from a network providerIn most cases, care you receive from an out-of-network provider (a provider who is not part of our plan's network) will not be covered. Here are three exceptions:
- The plan covers emergency care or urgently needed care that you get from an out-of-network provider. For more information about this, and to see what emergency or urgently needed care means, see the Evidence of Coverage Chapter 3.
- If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. In this care prior authorization is required. Please contact Member Services. If you obtain routine care from out-of-network providers without prior authorization, neither Medicare nor the Plan will be responsible for the costs. In this situation, we will cover these services as if you got the care from a network provider.
- Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan's service area.
How to get care from out-of-network providersIf you need medical care that Medicare requires our plan to cover and the providers in our Network cannot provider this care; you can get this care from an out-of-network provider. In this case a prior authorization is required. If you obtain routine from out-of-network providers without prior authorization, neither Medicare nor the Plan will be responsible for the costs.
*Printed copies of information posted on our website are available upon request.
Adobe Acrobat Reader is required to view the file(s) above. Download a free version.