Benefit Explanation: 3 Free Office Visits Per Year Per Family Member
Specialist
CoPay: Not Applicable
CoInsurance: 0.00% Coinsurance after deductible
Covered: Covered
Prescription Drug Information
Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 0.00% Coinsurance after deductible
Covered: Covered
Limit Quantity: 30
Limit Unit : Item(s) per Month
Benefit Explanation: Coverage limited to 90-day supply retail and mail order.
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 0.00% Coinsurance after deductible
Covered: Covered
Limit Quantity: 30
Limit Unit : Item(s) per Month
Benefit Explanation: Coverage limited to 90-day supply retail and mail order.
Generic Drugs
CoPay: Not Applicable
CoInsurance: 0.00% Coinsurance after deductible
Covered: Covered
Limit Quantity: 30
Limit Unit : Item(s) per Month
Benefit Explanation: See formulary for a listing of free preventive drugs. Coverage limited to 90-day supply for retail and mail order.
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 0.00% Coinsurance after deductible
Covered: Covered
Limit Quantity: 30
Limit Unit : Item(s) per Month
Benefit Explanation: Coverage limited to 30-day supply.
Inpatient Coverage
Hospital Services
CoPay: Not Applicable
CoInsurance: 0.00% Coinsurance after deductible
Covered: Covered
Inpatient Services
CoPay: Not Applicable
CoInsurance: 0.00% Coinsurance after deductible
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: Not Applicable
CoInsurance: 0.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Services provided by a non-participating provider will be paid at the participating provider level.
Urgent Care Facility
CoPay: Not Applicable
CoInsurance: 0.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Services provided by a non-participating provider will be paid at the participating provider level if for emergency medical care.
Maternity
Labor and Delivery Hospital Stay
CoPay: Not Applicable
CoInsurance: 0.00% Coinsurance after deductible
Covered: Covered
Exclusions: No coverage for home births.
Pre and Postnatal Office Visit
CoPay: Not Applicable
CoInsurance: 0.00% Coinsurance after deductible
Covered: Covered
Exclusions: No coverage for birthing classes.
Vision
Routine Eye Exams For Children
CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Exclusions: Coverage is limited to children through the last day of the calendar month of their 19th birthday; no coverage for services by a non-participating provider.",",",",Not Covered"
1-817-813-4562, TTY 711
