Benefit Explanation: No cost sharing applies for the first non-routine office visit with a Primary Care Provider. Additional non-routine office visits with a Primary Care Provider will take applicable cost sharing.
Specialist
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Prescription Drug Information
Preferred Brand Drugs
CoPay: $50.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Non Preferred Brand Drugs
CoPay: $100.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Generic Drugs
CoPay: $9.00
CoInsurance: Not Applicable
Covered: Covered
Specialty Drugs
CoPay: $250.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Exclusions: Specialty Drugs purchased through a non-contracted or non-specialty drug pharmacies will not be covered.
Inpatient Coverage
Hospital Services
CoPay: Not Applicable
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: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Urgent Care Facility
CoPay: $60.00
CoInsurance: Not Applicable
Covered: Covered
Maternity
Labor and Delivery Hospital Stay
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Pre and Postnatal Office Visit
CoPay: No Charge
CoInsurance: No Charge
Covered: Covered
Benefit Explanation: Routine Prenatal and Postnatal Care are covered in full.
Vision
Routine Eye Exams For Children
CoPay: $40.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year
Benefit Explanation: For Members under the age of 19.
1-817-813-4562, TTY 711
