Benefit Explanation: The Physician Office Copayment may be reduced or waived when services are rendered by a Provider participating in the Quality Blue Primary Care Program (QBPC). QBPC Providers include family practitioners, general practitioners, internists, nurse practitioners, geriatricians and physician assistants.
Specialist
CoPay: $65.00
CoInsurance: Not Applicable
Covered: Covered
Prescription Drug Information
Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Exclusions: Certain exclusion apply - Please see the contract book for a full list of pharmacy exclusions.
Benefit Explanation: Quantity per dispensing (QPD) limits/allowances are placed on certain medications and are based on the manufacturer's recommended dosage and duration of therapy, common usage for episodic or intermittent treatment, FDA-approved recommendations and/or clinical studies, and/or as determined by us. Note that for 3-tier plans, if a generic equivalent exists for a brand-name drug, plan participant must pay the Tier 1 copayment, plus the difference in cost between the brand-name drug dispensed and its generic equivalent. For 2-tier plans, the plan participant must pay the generic drug coinsurance, plus the difference in cost between the brand-name drug dispensed and its generic equivalent.
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Exclusions: Certain exclusion apply - Please see the contract book for a full list of pharmacy exclusions.
Benefit Explanation: Quantity per dispensing (QPD) limits/allowances are placed on certain medications and are based on the manufacturer's recommended dosage and duration of therapy, common usage for episodic or intermittent treatment, FDA-approved recommendations and/or clinical studies, and/or as determined by us. Note that for 3-tier plans, if a generic equivalent exists for a brand-name drug, plan participant must pay the tier 1 copayment, plus the difference in cost between the brand-name drug dispensed and its generic equivalent. For 2-tier plans, the plan participant must pay the generic drug coinsurance, plus the difference in cost between the brand-name drug dispensed and its generic equivalent.
Generic Drugs
CoPay: $7.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Exclusions: Certain exclusion apply - Please see the contract book for a full list of pharmacy exclusions.
Benefit Explanation: Quantity per dispensing (QPD) limits/allowances are placed on certain medications and are based on the manufacturer's recommended dosage and duration of therapy, common usage for episodic or intermittent treatment, FDA-approved recommendations and/or clinical studies, and/or as determined by us. All pharmacy plans have preventive drugs per USPSTF for $0. For 2-tier pharmacy plans, additional selected generic preventive care drugs in certain classes cost $0. For 3-tier pharmacy plans, additional selected drugs in certain classes used to treat selected chronic conditions cost $0.
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Exclusions: Certain exclusion apply - Please see the contract book for a full list of pharmacy exclusions.
Benefit Explanation: Specialty drugs are distributed throughout all tiers on both the 2-tier and 3-tier plans and the member is responsible to pay the applicable deductible/copay/coinsurance for that tier. Retail day supply limits (typically 30-day supply) apply. In addition, quantity per dispensing (QPD) limits/allowances are placed on certain specialty medications and are based on the manufacturer's recommended dosage and duration of therapy, common usage for episodic or intermittent treatment, FDA-approved recommendations and/or clinical studies, and/or as determined by us
Inpatient Coverage
Hospital Services
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Inpatient Bed, Board and General Nursing Services include but not limited to: 1. Hospital room and board and general nursing services. 2. In a Special Care Unit for a critically ill Member requiring an intensive level of care. 3. In a Skilled Nursing Facility or Unit or while receiving skilled nursing services in a Hospital, for the maximum number of days per Benefit Period shown in the Schedule of Benefits. 4. In a Residential Treatment Center for Members with Mental Disorders and Alcohol and/or Drug Abuse Benefits. B. Other Hospital Services (Inpatient and Outpatient) 1. Use of operating, delivery, recovery and treatment rooms and equipment. 2. Drugs and medicines including take-home Prescription Drugs. 3. Blood transfusions, including the cost of whole blood, blood plasma and expanders, processing charges, administrative charges, equipment and supplies. 4. Anesthesia, anesthesia supplies and anesthesia services rendered by a Hospital employee. 5. Medical and surgical supplies, casts, and splints. 6. Diagnostic Services rendered by a Hospital employee. 7. Physical Therapy provided by a Hospital employee. 8. Psychological testing when ordered by the attending Physician and performed by an employee of the hospital.
Inpatient Services
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Surgical services examples include but not limited to: 1. The Allowable Charge for Inpatient and Outpatient Surgery includes all pre-operative and postoperative medical visits. 2. Multiple Surgical Procedures - When Medically Necessary multiple procedures (concurrent, successive, or other multiple surgical procedures) are performed at the same surgical setting 3. Assistant Surgeon 4. General anesthesia services are covered when requested by the operating Physician and performed by a certified registered nurse anesthetist (CRNA) or Physician, other than the operating Physician or the assistant surgeon, for covered surgical services. Inpatient Medical Services - Subject to provisions in the sections pertaining to Surgery and Pregnancy Care in this Benefit Plan, Inpatient Medical Services include: 1. Inpatient medical care visits 2. Concurrent Care 3. Consultation (as defined in this Benefit Plan)
Emergency and Urgent Care
Emergency Room
CoPay: $450.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: The ER copayment is waived if the visit results in an Inpatient Admission.
Urgent Care Facility
CoPay: $65.00
CoInsurance: Not Applicable
Covered: Covered
Maternity
Labor and Delivery Hospital Stay
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Pre and Postnatal Office Visit
CoPay: $65.00
CoInsurance: Not Applicable
Covered: Covered
Vision
Routine Eye Exams For Children
CoPay: No Charge
CoInsurance: No Charge
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per Year
Major Dental Care
Routine Dental Checkups for Children
CoPay: No Charge
CoInsurance: No Charge
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per 6 Months
Benefit Explanation: Limitations may apply. Subject to Dental deductible, if applicable.
1-817-813-4562, TTY 711
