An explanation of each of these tier's, for the Non-Medicare eligilbe retirees and their dependents, is available by clicking here. *Please pay special attention to those services which would require prior authorization when reading this document.

Retirees and Dependents Over Age 65 enrolled in the Exclusive Care Select Medicare Coordination Plan. Call 1-800-962-1133 for additional information. The table consists of multiple rows with three columns, one column for Coverage Type, one for Tier 1 cost and one for tier 2 cost.

Retirees & Dependents Over Age 65 Exclusive Care Select Medicare Coordination  Call 1-800-962-1133 for additional information
Coverage Type	Tier 1- Exclusive Care Network	Tier 2- MultiPlan/PHCS Network or Providers who accepts Medicare Assignment
Annual Out-Pocket Maximum for Certain Services	$1,500/person $4,500/family	$2,500/person $7,500/family
Primary Care and Specialist Physician Office Visits	$10/primary care $20/specialist	$25/primary care $50/specialist
Inpatient Hospital Services (Mandatory Centers of Excellence apply)	90%	80% of Medicare allowable
Outpatient Facility Services   (Mandatory Centers of Excellence apply to some Outpatient Facility)	90%	80% of Medicare allowable
Hospital Emergency Room or Outpatient Facility (Mandatory Centers of Excellence apply to some Outpatient Facility)	$50 co-pay, then 90%	$100 co-pay, then 80%
Urgent Care Facility	$20 co-pay	$50 co-pay
Rehabilitative Therapy	90%	80% of Medicare allowable
Durable Medical Equipment	90%	80% of Medicare allowable
External Prosthetic Appliances	90%	80% of Medicare allowable
Home Health Services (up to 26 day/year)	90%	80% of Medicare allowable
Hospice Services	90%	80% of Medicare allowable
Skilled Nursing and Rehabilitation Facilities (100 visits maximum per member per contract year)	90%	80% of Medicare allowable
Laboratory and Radiology Services	90%	80% of Medicare allowable
Mental Health Inpatient Services (Mandatory Centers of Excellence apply)	90%	80% of Medicare allowable
Mental Health Outpatient Services (30 days maximum per member per contract year, unless Severe Mental Illness - Mandatory Centers of Excellence apply)	$20 co-pay
Substance Abuse Detoxification Inpatient Services (Mandatory Centers of Excellence apply)	90%	80% of Medicare allowable
Substance Abuse Detoxification Outpatient Services (30 days maximum per member per contract year – Mandatory Centers of Excellence apply)	$20 co-pay
Vision Care: Eye Exam	$10 co-pay	$25 co-pay
Vision Care: One Pair of Approved Glasses	Not Covered
Participating Retail Pharmacy (up to 30 day supply)	Generic: $15 co-pay Brand-name formulary: $25 co-pay Non-formulary Brand: $40 co-pay Significant or new therapeutic class drugs: 50%
Participating Mail-Order pharmacy (up to a 90 day supply)   Mail-order is MANDATORY for maintenance medications	Generic: $30 co-pay Brand-name formulary: $50 co-pay Non-formulary Brand: $80 co-pay
This is a summary of the frequently asked about benefits. This chart is not meant to be a comprehensive explanation of benefits, cost sharing, exclusions or limitations. For a complete explanation of benefits, please refer to the Summary Plan Document (SPD).