Benefit Explanation: $0 copay after deductible for children under age 5. There is no charge for the first Primary Care, Other Practitioner, Routine Eye Exam, Mental/Behavioral Health, Substance Abuse Disorder, Diabetes Education and Nutritional Counseling office visits combined; then the primary care cost share applies for all subsequent office visits or services.
Specialist
CoPay: $70.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Prescription Drug Information
Preferred Brand Drugs
CoPay: $50.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Generic Drugs
CoPay: $10.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Inpatient Coverage
Hospital Services
CoPay: $300.00 Copay per Day after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: $300 copay per day up to 3 days per admission.
Inpatient Services
CoPay: No Charge after deductible
CoInsurance: Not Applicable
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: $200.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Urgent Care Facility
CoPay: $70.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Non-plan providers are covered only outside the service area.
Maternity
Labor and Delivery Hospital Stay
CoPay: $300.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: $300 copay per day up to 3 days per admission.
Pre and Postnatal Office Visit
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Vision
Routine Eye Exams For Children
CoPay: $50.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Benefit Period
Benefit Explanation: There is no charge for the first Primary Care, Other Practitioner, Routine Eye Exam, Mental/Behavioral Health, Substance Abuse Disorder, Diabetes Education and Nutritional Counseling office visits combined; then the primary care cost share applies for all subsequent office visits or services.
Major Dental Care
Routine Dental Checkups for Children
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 2
Limit Unit : Exam(s) per Benefit Period
Benefit Explanation: $10 office visit charge applies to each visit
Basic Dental Care - Child
CoPay: Not Applicable
CoInsurance: 33.00%
Covered: Covered
Benefit Explanation: Benefit limitations may apply to individual services.
Major Dental Care - Child
CoPay: Not Applicable
CoInsurance: 39.00%
Covered: Covered
Benefit Explanation: Benefit limitations may apply to individual services.
1-817-813-4562, TTY 711
