Plan Resources

Summary of Benefits

Summary of Benefits includes the following information:

  • Monthly premium
  • Service area
  • Applicable conditions and limitations
  • Conditions associated with use of benefits
  • Copayments, coinsurance, and deductibles
  • Out-of-network coverage

Download the Summary of Benefits:

Download Summary of Benefits (Select Plan) - English

Download Summary of Benefits (Enhanced Plan) - English

 

Download Summary of Benefits (Select Plan) - Español

Download Summary of Benefits (Enhanced Plan) - Español

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Medicare Complaint Form: Click the link below to submit feedback about your prescription drug plan directly to Medicare:
https://www.medicare.gov/MedicareComplaintForm/home.aspx