Benefit Explanation: Cost share applies to both in-person and virtual services from in-network providers. Cost share does not apply to virtual services from designated telemedicine providers. If this is an HSA plan, deductible applies.
Specialist
CoPay: $80.00
CoInsurance: Not Applicable
Covered: Covered
Prescription Drug Information
Preferred Brand Drugs
CoPay: $195.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details.
Non Preferred Brand Drugs
CoPay: $275.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details.
Generic Drugs
CoPay: $3.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details.
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Cost share could vary based on drug and pharmacy selected. Please see the Summary of Benefits & Coverage (SBC) or policy document for plan details.
Inpatient Coverage
Hospital Services
CoPay: $2500.00 Copay per Day
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Copay per day for days 1-3
Inpatient Services
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: $2,500.00
CoInsurance: Not Applicable
Covered: Covered
Exclusions: No coverage for non-emergency use of the emergency room.
Urgent Care Facility
CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered
Exclusions: No coverage for non-urgent care.
Maternity
Labor and Delivery Hospital Stay
CoPay: $2,500.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Copay per day for days 1-3
Pre and Postnatal Office Visit
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Member cost share applies to postnatal care.
Vision
Routine Eye Exams for Children
CoPay: $10.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year
Benefit Explanation: Coverage is limited to 1 exam every 12 months, through the end of the month in which the member turns 19.
Major Dental Care
Routine Dental Checkups for Children
Covered: Not Covered
Routine Dental Checkups for Adults
CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Limit Quantity: 2
Limit Unit : Visit(s) per Year
Benefit Explanation: Coverage is limited to ages 19 and up. $1,000 calendar year maximum for all dental services (Routine check-up, Basic & Major).
This site is not the Health Insurance Marketplace website, and the link to the FFM website is
1-817-813-4562, TTY 711
