Benefit Explanation: This plan includes one annual physical/wellness exam at no cost to the member.
Specialist
CoPay: $90.00
CoInsurance: Not Applicable
Covered: Covered
Prescription Drug Information
Preferred Brand Drugs
CoPay: $75.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Refer to the drug list for quantity limits and other exclusions.
Non Preferred Brand Drugs
CoPay: $100.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Refer to the drug list for quantity limits and other exclusions.
Generic Drugs
CoPay: $5.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Refer to the drug list for quantity limits and other exclusions.
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Refer to the drug list for quantity limits and other exclusions.
Inpatient Coverage
Hospital Services
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Inpatient Services
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: $250.00 Copay after deductible
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Urgent Care Facility
CoPay: $75.00
CoInsurance: Not Applicable
Covered: Covered
Maternity
Labor and Delivery Hospital Stay
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Pre and Postnatal Office Visit
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Routine care is covered as preventive. Complications of Pregnancy is diagnostic/medical care will be covered as indicated by the SBC document.
Vision
Routine Eye Exams For Children
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year
Benefit Explanation: One exam per year. See SBC for details.
1-817-813-4562, TTY 711
