Benefit Explanation: Limited to a 30-day supply of Prescription Drugs.
Non Preferred Brand Drugs
CoPay: $25.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Limited to a 30-day supply of Prescription Drugs.
Generic Drugs
CoPay: $5.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Limited to a 30-day supply of Prescription Drugs.
Specialty Drugs
CoPay: $100.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Limited to a 30-day supply of Prescription Drugs.
Inpatient Coverage
Hospital Services
CoPay: $250.00 Copay per Day
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: $250 copay per day up to 5 days per admission. Prior authorization is required except for emergency admissions and all maternity admissions.
Inpatient Services
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: $150.00
CoInsurance: Not Applicable
Covered: Covered
Urgent Care Facility
CoPay: $40.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Non-plan providers are covered only outside the service area.
Maternity
Labor and Delivery Hospital Stay
CoPay: $250.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: $250 copay per day up to 5 days per admission.
Pre and Postnatal Office Visit
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Vision
Routine Eye Exams For Children
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Benefit Period
Major Dental Care
Routine Dental Checkups for Children
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 2
Limit Unit : Procedure(s) per Benefit Period
Benefit Explanation: $10 office visit charge applies to each visit
Basic Dental Care - Child
CoPay: Not Applicable
CoInsurance: 33.00%
Covered: Covered
Benefit Explanation: Benefit limitations may apply to individual services.
Major Dental Care - Child
CoPay: Not Applicable
CoInsurance: 39.00%
Covered: Covered
Benefit Explanation: Benefit limitations may apply to individual services.
1-817-813-4562, TTY 711
