Benefit Explanation: Your Prescription Drug benefits may include a Formulary ... which is a list of Brand Name Prescription Drugs that are preferred by your Plan. We may remind your Physician or Professional Other Provider when a Formulary medication is available for a medication that is not on your Formulary. This may result in a change in your Prescription. However, your Physician or Professional Other Provider will always make the final decision on your medication.'
Generic Drugs
CoPay: $0.00
CoInsurance: Not Applicable
Covered: Covered
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 50.00%
Covered: Covered
Inpatient Coverage
Hospital Services
CoPay: $375.00 Copay per Stay
CoInsurance: Not Applicable
Covered: Covered
Inpatient Services
CoPay: Not Applicable
CoInsurance: 20.00%
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: $250.00
CoInsurance: Not Applicable
Covered: Covered
Urgent Care Facility
CoPay: $30.00
CoInsurance: Not Applicable
Covered: Covered
Maternity
Labor and Delivery Hospital Stay
CoPay: $375.00
CoInsurance: Not Applicable
Covered: Covered
Pre and Postnatal Office Visit
CoPay: Not Applicable
CoInsurance: 20.00%
Covered: Covered
Vision
Routine Eye Exams For Children
CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year
Major Dental Care
Routine Dental Checkups for Children
CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Limit Quantity: 2
Limit Unit : Visit(s) per Year
Routine Dental Checkups for Adults
CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Benefit Explanation: Adult dental services have a separate $50 deductible
1-817-813-4562, TTY 711
