Benefit Explanation: First two in-person visits covered at $1 copay, then regular copay amounts apply. This two-visit allowance is shared with Other Practitioner Office Visit (Nurse, Physician Assistant).
Specialist
CoPay: $100.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Prescription Drug Information
Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Limit Quantity: 90
Limit Unit : Days per Month
Benefit Explanation: Coverage is limited to a 90-day supply retail or 90-day supply mail order per fill or refill. Insulin limit: $35 for a 30 day supply and $105 for a 90 day
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Limit Quantity: 90
Limit Unit : Days per Month
Benefit Explanation: Coverage is limited to a 90-day supply retail or 90-day supply mail order per fill or refill. Insulin limit: $35 for a 30 day supply and $105 for a 90 day
Generic Drugs
CoPay: $32.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 90
Limit Unit : Days per Month
Benefit Explanation: Coverage is limited to a 90-day supply retail or 90-day supply mail order per fill or refill. Insulin limit: $35 for a 30 day supply and $105 for a 90 day
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Limit Quantity: 30
Limit Unit : Days per Month
Benefit Explanation: First fill allowed at a retail pharmacy. Additional fills must be provided at a specialty pharmacy. Coverage is limited to a 30-day supply for specialty and self-administrable cancer chemotherapy medications from a specialty pharmacy per fill or refill. Specialty medications that fall into Tier 6 Specialty are non-preferred medications and covered at 50% coinsurance after deductible. Insulin: Insulin limit of $35 for a 30 day supply and $105 for a 90 day supply
Inpatient Coverage
Hospital Services
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Inpatient Services
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Out of service area coverage is available.
Urgent Care Facility
CoPay: $100.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Out of service area coverage is available.
1-817-813-4562, TTY 711
