Benefit Explanation: Adherence Generics are available at $0 copay or 0% coinsurance after deductible for certain categories of medications.
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: The coinsurance for Non-preferred specialty drugs is 10% higher than Preferred Specialty drugs. There is No Cost for covered Specialty Drugs for the Native American/Alaskan Limited and Zero Cost share plans.
Inpatient Coverage
Hospital Services
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Inpatient Services
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: $350.00
CoInsurance: Not Applicable
Covered: Covered
Urgent Care Facility
CoPay: $60.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Urgent Care Outside the Service Area is only covered when furnished by an Emergency room or Hospital-based Urgent Care Facility.
Maternity
Labor and Delivery Hospital Stay
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Pre and Postnatal Office Visit
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Vision
Routine Eye Exams For Children
CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Benefit Explanation: 1 Exam per year
Major Dental Care
Routine Dental Checkups for Children
CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Benefit Explanation: One exam, cleaning, and X-ray per year
Routine Dental Checkups for Adults
CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Benefit Explanation: One exam, cleaning, and X-ray per year
1-817-813-4562, TTY 711
