Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Specialist
CoPay: $65.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Prescription Drug Information
Preferred Brand Drugs
CoPay: $55.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Non Preferred Brand Drugs
CoPay: $80.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Generic Drugs
CoPay: $15.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 20.00%
Covered: Covered
Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Inpatient Coverage
Hospital Services
CoPay: Not Applicable
CoInsurance: 20.00%
Covered: Covered
Benefit Explanation: This includes labor and delivery, mental health, and substance use disorder facility fee.
Inpatient Services
CoPay: Not Applicable
CoInsurance: 20.00%
Covered: Covered
Benefit Explanation: This Includes labor and delivery, mental health, and substance use disorder professional fee.
Emergency and Urgent Care
Emergency Room
CoPay: $350.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Urgent Care Facility
CoPay: $35.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Maternity
Labor and Delivery Hospital Stay
CoPay: Not Applicable
CoInsurance: 20.00%
Covered: Covered
Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Pre and Postnatal Office Visit
CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Vision
Routine Eye Exams For Children
CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
Major Dental Care
Routine Dental Checkups for Children
CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Benefit Explanation: Please see plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) or policy document for complete information on benefits and exclusions.
1-817-813-4562, TTY 711
