Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.
Non Preferred Brand Drugs
CoPay: No Charge after deductible
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.
Generic Drugs
CoPay: $15.00
CoInsurance: Not Applicable
Covered: Covered
Exclusions: Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.
Specialty Drugs
CoPay: No Charge after deductible
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Exclusions: Coinsurance up to applicable maximum per prescription. Cost sharing could vary based on drug and pharmacy selected. Please see SBC for full plan details.
Inpatient Coverage
Hospital Services
CoPay: No Charge after deductible
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Inpatient Services
CoPay: No Charge after deductible
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: No Charge after deductible
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Exclusions: No coverage for non-emergency use of the emergency room.
Urgent Care Facility
CoPay: $35.00
CoInsurance: Not Applicable
Covered: Covered
Maternity
Labor and Delivery Hospital Stay
CoPay: No Charge after deductible
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Pre and Postnatal Office Visit
CoPay: No Charge after deductible
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Exclusions: Member cost sharing applies to postnatal care
Vision
Routine Eye Exams For Children
CoPay: No Charge after deductible
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per Year
Exclusions: Coverage is limited to 1 exam per calendar year age 0-19.
1-817-813-4562, TTY 711
