Benefit Explanation: Virtual medical visit with a Dedicated Virtual Care Physician is covered at No Charge. Refer to the policy for more information. Includes Mental Health Office Visits and Substance Use Disorder Office Visits.
Specialist
CoPay: $65.00
CoInsurance: Not Applicable
Covered: Covered
Prescription Drug Information
Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: 30 day supply at any Participating Pharmacy or Up to a 90 day supply at a 90 day Retail Pharmacy. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information.
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: 30 day supply at any Participating Pharmacy or Up to a 90 day supply at a 90 day Retail Pharmacy.
Generic Drugs
CoPay: $0.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Cost sharing shown applies to Tier 1-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 2-Generic Drugs, which may apply a higher cost share. 30 day supply at any Participating Pharmacy or up to a 90 day supply at a 90 day Retail Pharmacy. You pay a copayment for each 30 day supply. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information.
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Including other high cost drugs. 30 day supply at any Participating Pharmacy or Up to a 90 day supply at a 90 day Retail Pharmacy.
Inpatient Coverage
Hospital Services
CoPay: $500.00 Copay per Stay with deductible
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Inpatient Services
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: $1000.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Out-of-network: You pay the same level as in-network if it is an emergency as defined in your plan, otherwise Not covered.
Urgent Care Facility
CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Out-of-network: You pay the same level as in-network if it is an emergency as defined in your plan, otherwise Not covered.
Maternity
Labor and Delivery Hospital Stay
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Inpatient facility benefit applies for inpatient hospital stay.
Pre and Postnatal Office Visit
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Vision
Routine Eye Exams For Children
CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year
Benefit Explanation: Children up to age 19, through the end of their birth month.
Major Dental Care
Routine Dental Checkups for Children
Covered: Not Covered
Basic Dental Care - Child
Covered: Not Covered
Major Dental Care - Child
Covered: Not Covered
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