Benefit Explanation: All visits with a Doctor On Demand Provider will be at the PCP copayment amount. Visits with non-Doctor on Demand providers require a referral from Doctor on Demand to be covered under this plan.
Specialist
CoPay: $65.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Any visit with a non-Doctor on Demand provider will be at the Specialist copayment amount. Visits with non-Doctor on Demand providers require a referral from Doctor on Demand to be covered under this plan.
Prescription Drug Information
Preferred Brand Drugs
CoPay: $75.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Refer to the drug list for quantity limits and other exclusions.
Non Preferred Brand Drugs
CoPay: $125.00
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
Benefit Explanation: A visit with your designated Doctor on Demand telehealth primary care physician (PCP) is required to obtain a referral to a specialist or for other necessary medical services.
Inpatient Services
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: A visit with your designated Doctor on Demand telehealth primary care physician (PCP) is required to obtain a referral to a specialist or for other necessary medical services.
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
Benefit Explanation: A visit with your designated Doctor on Demand telehealth primary care physician (PCP) is required to obtain a referral to a specialist or for other necessary medical services.
Maternity
Labor and Delivery Hospital Stay
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: A visit with your designated Doctor on Demand telehealth primary care physician (PCP) is required to obtain a referral to a specialist or for other necessary medical services.
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: A visit with your designated Doctor on Demand telehealth primary care physician (PCP) is required to obtain a referral to a specialist or for other necessary medical services. One exam per year. See SBC for details.
1-817-813-4562, TTY 711
