2012 Plans
ODS Advantage PPO RX Select Plan (PPO MAPD)
ODS Advantage PPO Plan (PPO MA)
Benefit Information
2012
Summary of Benefits (PDF)
2012
Evidence of Coverage (PDF)
2012
Benefit Comparison Flyer (PDF)
Enrollment Forms
Enrollment
Form (PDF)
Dental Enrollment
Form (PDF)
EFT Form
Providers, Pharmacies & Drugs
Provider Directory
Pharmacy
Directory
2012
Formulary (PDF)
ODS Advantage PPO benefits
The ODS Advantage PPO plan features a number of valuable medical benefits designed to help you manage your health including:
- Annual out-of-pocket maximum of
$3400
- $40 deductible
- $0 copayment for your annual physical
- Routine vision exam benefit once every two years
- Travel and visitor coverage for up to 12 months in the USA
- Worldwide coverage for
emergency medical services
ODS Advantage PPORX Select (PPO) benefits
The ODS Advantage PPORX Select plan features valuable medical and prescription drug benefits designed to help you manage your health. Some of the highlights of this plan include:
Medical benefits
- Annual out-of-pocket maximum of $3,400 which includes both in and out of network services
- Low deductible of $40
- $0 copayment for your annual physical
- Routine vision exam benefit once every two years
- See any Medicare provider in- or out-of-network
- Travel and visitor coverage for up to 12 months in the USA
- Worldwide coverage for emergency medical services
Prescription drug benefits
- $120 annual deductible, after which you pay the following:
- 10% coinsurance for Tier 1 generics
- 32% coinsurance for Tier 2 high cost generic and preferred brand
- 50% coinsurance for Tier 3 non-preferred brand drugs
- 30% coinsurance for Tier 4 Specialty drugs
- When your total drug costs reach $2,840, you pay the following:
- 93% percent coinsurance for generic drugs and you receive a discount on brand-name drugs until your annual out-of-pocket drug costs reach the $4,550 Catastrophic coverage limit (out of
pocket maximum
- After your annual out-of-pocket drug costs reach $4,550, you pay the greater of:
- $2.50 for generic (including brand-name drugs treated as generic) and $6.30 for all other drugs OR
- 5 percent coinsurance
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