Monthly Premium, Deductible and Limits 
PLAN COSTS 
Monthly plan premium 
You must keep paying your 
Medicare Part Bpremium. $74 
If you receive premium assistance, your plan 
premium may be reduced.  
Medical deductible This plan does not have adeductible.  
Pharmacy (Part D) deductible No deductible for Tier 1, Tier 2and Tier 3
$250 for Tier 4, Tier 5
Maximum out-of-pocket 
responsibility 
The most you pay for copays, 
coinsurance and other costs for 
covered medical services for the