2013 Trillium Advantage Rx Smart HMO
A Plan With Prescription Drug Coverage
If you live in Lane County and are looking for a more affordable Medicare Advantage plan, pick Trillium Advantage Rx Smart.
You will receive substantial coverage for medical expenses and protection for potential prescription costs.
There are no limitations based on age and the price is right.
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or download an enrollment form and mail it to Trillium:
If you do not prefer drug coverage, pick
Trillium Advantage HMO
- No deductibles
- No referrals
- No Primary Care Provider (PCP) requirements
- Limited out-of-pocket costs
- Low or no co-pays for doctor and specialists' visits
- Access to over 1,400 Lane County physicians
- Access to worldwide emergency care when you travel
- Friendly, responsive customer service
- Prescription coverage through the coverage gap
- Access to all pharmacies in Lane County
- A convenient pharmacy mail-order service
- Coverage for over 3,200 brand name and generic drugs.
Our prescription drug benefits cover more than Medicare requires and gives extra
protection against higher out-of-pocket costs.
- Coverage for preventive services and screenings (including HIV Screenings)
Plan Specific Documents
- Evidence of Coverage
- Formulary List Changes
- Low Income Subsidy Premium Summary
- Member Rights and Responsibilities
- Multi-language Interpreter Services
- Out-of-Network Coverage rules
- Summary of Benefits
Trillium Advantage Rx Smart HMO Overview Chart
|Provider Office||$15 co-pay|
|Specialist Visit (no referrals required)||$25 co-pay|
|X-Ray & Lab||$0-15 co-pay|
|Preventive Services||$0 co-pay|
|Inpatient Hospital||Days 1-7:
Days 8-90: $0/day
|Skilled Nursing Facility||Days 1-20: $0/day
Days 21-100: $100/day
|Emergency Room (worldwide service)||$65|
|Urgent Care (worldwide service)||$40 co-pay|
|Prescription Drugs||Phase I - Initial Coverage:
Tier 1 generic drugs: $8 for 1 month or $24 for 3 months
Tier 2 brand name: $45 a month $135 for 3 months
Tier 3 non-preferred: $80 a month $240 for 3 months
Tier 4 33% specialty drugs
|Phase II - Coverage Gap:
Phase II begins when total drug costs reach $2,970
21% discount generic
52.5% discount brand
|Phase III - Catastrophic:
Phase III begins when out-of-pocket drug costs reach $4,750
$2.60 for generic drugs
$6.50 or 5% coinsurance for all other drugs.
The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium.