Benefit Explanation: Primary Care Office Visits covered in full for first 5 office visits. Visits 6+ subject to copay. Copay is for office visit only, other services provided during the visit are subject to additional cost shares. The first 5 copays accumulates across Primary Care Office Visits, Other Practitioner Office Visits (Nurse, Physician Assistant), and Virtual visits. You may also be able to access care with lower cost shares using our designated network of virtual doctors. These designated virtual doctors can be accessed via our mobile application, website, or HealthKeepers enabled device. Doctor Visits in the Home are covered.
Specialist
CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Specialists Copay is for office visit only, other services provided during the visit are subject to additional cost shares. Mental Health and Substance Use Office Visits apply deductible/coinsurance. Copays do not apply to these services. You may also be able to access care with lower cost shares using our designated network of virtual doctors. These designated virtual doctors can be accessed via our mobile application, website, or HealthKeepers enabled device.
Prescription Drug Information
Preferred Brand Drugs
CoPay: $45.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: 30 day supply retail. The per-Member Cost Share for a covered prescription drug that contains insulin and is used to treat diabetes will not exceed a total of $50 per 30-day supply when obtained in-network. For FDA-approved, self administered Hormonal Contraceptives, up to a 12-month supply is covered when dispensed or furnished at one time by a Provider or pharmacist, or at a location licensed or otherwise authorized to dispense drugs or supplies.
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 45.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: 30 day supply retail. The per-Member Cost Share for a covered prescription drug that contains insulin and is used to treat diabetes will not exceed a total of $50 per 30-day supply when obtained in-network. For FDA-approved, self administered Hormonal Contraceptives, up to a 12-month supply is covered when dispensed or furnished at one time by a Provider or pharmacist, or at a location licensed or otherwise authorized to dispense drugs or supplies.
Generic Drugs
CoPay: $5.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: 30 day supply retail. The per-Member Cost Share for a covered prescription drug that contains insulin and is used to treat diabetes will not exceed a total of $50 per 30-day supply when obtained in-network. For FDA-approved, self administered Hormonal Contraceptives, up to a 12-month supply is covered when dispensed or furnished at one time by a Provider or pharmacist, or at a location licensed or otherwise authorized to dispense drugs or supplies.
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: 30 day supply. The per-Member Cost Share for a covered prescription drug that contains insulin and is used to treat diabetes will not exceed a total of $50 per 30-day supply when obtained in-network. For FDA-approved, self administered Hormonal Contraceptives, up to a 12-month supply is covered when dispensed or furnished at one time by a Provider or pharmacist, or at a location licensed or otherwise authorized to dispense drugs or supplies.
Inpatient Coverage
Hospital Services
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: The coinsurance shown is for services provided in Tier 1 hospitals and facilities. If you choose a Tier 2 hospital or facility, you will have a higher coinsurance.
Inpatient Services
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Urgent Care Facility
CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered
Maternity
Labor and Delivery Hospital Stay
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: This benefit is for the hospital stay. The coinsurance shown is for services provided in Tier 1 hospitals and facilities. If you choose a Tier 2 hospital or facility, you will have a higher coinsurance.
Pre and Postnatal Office Visit
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Vision
Routine Eye Exams for Children
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per Benefit Period
Benefit Explanation: Includes complete eye exam with dilation, as needed to check all aspects of vision, including the structure of the eyes. Limited to 1 visit per year.
Major Dental Care
Routine Dental Checkups for Children
CoPay: No Charge after deductible
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 2
Limit Unit : Visit(s) per Year
Benefit Explanation: Limited to 2 visits per year.
1-817-813-4562, TTY 711
