Benefit Explanation: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill.
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Limit Quantity: 30
Limit Unit : Days per Month
Benefit Explanation: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill.
Generic Drugs
CoPay: $3.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 30
Limit Unit : Days per Month
Benefit Explanation: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. 87718WA2170001 both WAF005, WAF016 apply; 87718WA2170002 both WAF002, WAF012 apply; 87718WA2170003 both WAF010, WAF014 apply. Generic Drug cost share represents Preferred Generic Drugs in Tier 1. Non-preferred Generic Drugs that fall into Tier 2 are covered at a higher cost share.
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
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 per fill or refill. Specialty medications that fall into Tier 6 Specialty are non-preferred medications and covered at 50% coinsurance after deductible.
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: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Out of service area coverage is available.
1-817-813-4562, TTY 711
