Exclusions: 24/7 online doctor visits available with BlueCare Anywhere - see SBC for more information.
Benefit Explanation: 24/7 online doctor visits available with BlueCare Anywhere - see SBC for more information.
Specialist
CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered
Prescription Drug Information
Preferred Brand Drugs
CoPay: $70.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Exclusions: Excludes medications not on the formulary, unless a formulary exception is approved.
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Exclusions: Excludes medications not on the formulary, unless a formulary exception is approved.
Generic Drugs
CoPay: $3.00
CoInsurance: Not Applicable
Covered: Covered
Exclusions: Excludes medications not on the formulary, unless a formulary exception is approved.
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 50.00%
Covered: Covered
Exclusions: Excludes medications not on the formulary, unless a formulary exception is approved.
Inpatient Coverage
Hospital Services
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Inpatient Services
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Urgent Care Facility
CoPay: $60.00
CoInsurance: Not Applicable
Covered: Covered
Maternity
Labor and Delivery Hospital Stay
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Newborn benefits do not apply to the newly born child of an Eligible Dependent daughter unless placement with the contract holder or covered spouse is confirmed through a court order or legal guardianship.
Pre and Postnatal Office Visit
CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered
Vision
Routine Eye Exams For Children
CoPay: $15.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per Year
Benefit Explanation: Limit of 1 routine vision exam per calendar year.
Major Dental Care
Routine Dental Checkups for Children
CoPay: No Charge
CoInsurance: No Charge
Covered: Covered
Limit Quantity: 2
Limit Unit : Visit(s) per Year
Benefit Explanation: Limit of 2 dental check-ups & cleanings per year.
1-817-813-4562, TTY 711
