Benefit Explanation: The cost sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply. Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: The cost sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply. Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.
Generic Drugs
CoPay: $15.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: The cost sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply. Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: The cost sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply. Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.
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: Benefits are available in a Hospital Emergency Room or an independent, free-standing emergency facility for services and supplies to treat the onset of symptoms for a medical emergency.
Urgent Care Facility
CoPay: $75.00
CoInsurance: Not Applicable
Covered: Covered
Exclusions: No coverage for non-urgent care.
Maternity
Labor and Delivery Hospital Stay
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Pre and Postnatal Office Visit
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Member cost sharing applies to postnatal care
Vision
Routine Eye Exams For Children
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year
Exclusions: Coverage is limited to 1 exam every 12 months. Age 0 - 19.
1-817-813-4562, TTY 711
