Exclusions: Missed appointments and get acquainted visits. See policy for more information.
Specialist
CoPay: $40.00
CoInsurance: Not Applicable
Covered: Covered
Exclusions: Missed appointments and get acquainted visits. See policy for more information.
Prescription Drug Information
Preferred Brand Drugs
CoPay: $60.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 30
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. See policy for more information.
Non Preferred Brand Drugs
CoPay: $100.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 30
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. See policy for more information.
Generic Drugs
CoPay: $10.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 30
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. See policy for more information.
Specialty Drugs
CoPay: $100.00
CoInsurance: Not Applicable
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. See policy for more information.
Inpatient Coverage
Hospital Services
CoPay: $525.00 Copay per Day
CoInsurance: Not Applicable
Covered: Covered
Exclusions: Charges for inpatient stays that began before you were covered by this plan.
Benefit Explanation: Per day copay, limit of 5 copays per stay. Copay for All Inpatient Hospital Services includes the facility fee and professional service charges.
Inpatient Services
CoPay: Not Applicable
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Charges and coverage for Inpatient Physician and Surgical Services are included under the benefit for Inpatient Hospital Services.
Emergency and Urgent Care
Emergency Room
CoPay: $450.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Exclusions: Charges for inpatient stays that began before you were covered by this plan.
Urgent Care Facility
CoPay: $35.00
CoInsurance: Not Applicable
Covered: Covered
Maternity
Labor and Delivery Hospital Stay
CoPay: $525.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Per day copay, limit of 5 copays per stay.
Pre and Postnatal Office Visit
CoPay: $15.00
CoInsurance: Not Applicable
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
Exclusions: Orthoptics, vision therapy, or other services to correct refractive error.
Benefit Explanation: Coverage is provided until at least the end of the month in which the enrollee turns 19 years of age. See policy for more information.
1-817-813-4562, TTY 711
