* Services may require prior authorization from the plan.

** Diabetic supplies are limited to specific manufacturers. Test strips and monitors: One Touch, Accu-Check. Continuous glucose monitors available from Freestyle Libre or Dexcom after completing a prior authorization.

*** Home exercise program for $10 or $25 yearly membership at a Silver & Fit Fitness Center.

Initial Coverage Limit is $4,660.00. During the Initial Coverage state, the plan pays its share of the cost of your covered prescriptions and you pay your share (your copayment or coinsurance amount). Your share of the cost will vary depending on the drug and where you fill your prescription. Please review the Evidence of Coverage online for more information on the phases of the benefit.

You stay in this stage until your out of pocket costs reach a total of $7,400.00. When you are in the Coverage Gap Stage, the Medicare Coverage Gap Discount Program provides manufacturer discounts on brand name drugs. You pay 25% of the negotiated price and a portion of the dispensing fees for brand name drugs. Please review the Evidence of Coverage online for more information on the Coverage Gap Stage.

Catastrophic Coverage Limit is $7,400.00. Catastrophic coverage begins after your total yearly drug cost reaches $7,400.00. During this time, the plan pays most of the cost for your drugs. Please reference the Evidence of Coverage, available online, for complete information regarding the Catastrophic Coverage Stage.

Summary of Benefits (PDF) (updated 6/13/23)

The Summary of Benefits provides an overview of the plan benefits.

Enrollment Form (PDF) (updated 1/26/23)

If you would like to enroll for one of our plans, you can complete the Enrollment Form and mail it to us.

Evidence of Coverage - Central Tennessee (PDF) (updated 4/27/23)

The Evidence of Coverage explains your plan benefits, your rights and responsibilities, and provides you with important contact information.

Evidence of Coverage - Knoxville Tennessee (PDF) (updated 4/27/23)

The Evidence of Coverage explains your plan benefits, your rights and responsibilities, and provides you with important contact information.

Evidence of Coverage - Tri-Cities Tennessee (PDF) (updated 4/27/23)

The Evidence of Coverage explains your plan benefits, your rights and responsibilities, and provides you with important contact information.

Pharmacy Directory(PDF) (updated 8/22/23)

The Pharmacy Directory provides you with a list of network pharmacies and their locations.

Comprehensive Formulary (PDF) (updated 9/1/23)

The Comprehensive Formulary is the list of drugs covered by this plan. The formulary also tells you if a drug is restricted.

Comprehensive Formulary - Large Print (PDF) (updated 9/1/23)

The Comprehensive Formulary is the list of drugs covered by this plan. The formulary also tells you if a drug is restricted.

Prior Authorization Criteria (PDF) (Updated 9/1/23)

The Prior Authorization Criteria explains what is needed to review certain drugs that require prior authorization.

Step Therapy Criteria (PDF) (Updated 9/1/23)

The Step Therapy Criteria explains what is needed to review certain drugs that require step therapy.

Quantity Limits Criteria (PDF) (Updated 9/1/23)

The Quantity Limits Criteria explains what is needed to review certain drugs with quantity limits.

CMS Star Ratings (PDF)

The Medicare program uses a 5 star system to rate all prescription drug plans based on quality and performance.