Benefit Explanation: Including doctor visits in the home and online visits.
Specialist
CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Prescription Drug Information
Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Benefit Explanation: Covers prescription legend drugs from either a Retail Pharmacy or the PBM’s Home Delivery Pharmacy; self-administered injectable drugs; self-injectable insulin and supplies and equipment used to administer insulin; self-administered contraceptives, including oral contraceptive drugs, self-injectable contraceptive drugs, contraceptive patches, and contraceptive rings. Certain contraceptives are covered under the 'Preventive Care' benefit. Includes coverage for special food products or supplements when prescribed by a Doctor when medically necessary; Flu Shots (including administration). Inpatient or IV therapy drugs used in the treatment of cancer pain will not be denied on the basis that the dosage exceeds the recommended dosage of the pain relieving agent, if prescribed in compliance with established statutes pertaining to patients with intractable cancer pain. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply.
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Benefit Explanation: Covers prescription legend drugs from either a Retail Pharmacy or the PBM’s Home Delivery Pharmacy; self-administered injectable drugs; self-injectable insulin and supplies and equipment used to administer insulin; self-administered contraceptives, including oral contraceptive drugs, self-injectable contraceptive drugs, contraceptive patches, and contraceptive rings. Certain contraceptives are covered under the 'Preventive Care' benefit. Includes coverage for special food products or supplements when prescribed by a Doctor when medically necessary; Flu Shots (including administration). Inpatient or IV therapy drugs used in the treatment of cancer pain will not be denied on the basis that the dosage exceeds the recommended dosage of the pain relieving agent, if prescribed in compliance with established statutes pertaining to patients with intractable cancer pain. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply.
Generic Drugs
CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Benefit Explanation: Covers prescription legend drugs from either a Retail Pharmacy or the PBM’s Home Delivery Pharmacy; self-administered injectable drugs; self-injectable insulin and supplies and equipment used to administer insulin; self-administered contraceptives, including oral contraceptive drugs, self-injectable contraceptive drugs, contraceptive patches, and contraceptive rings. Certain contraceptives are covered under the 'Preventive Care' benefit. Includes coverage for special food products or supplements when prescribed by a Doctor when medically necessary; Flu Shots (including administration). Inpatient or IV therapy drugs used in the treatment of cancer pain will not be denied on the basis that the dosage exceeds the recommended dosage of the pain relieving agent, if prescribed in compliance with established statutes pertaining to patients with intractable cancer pain. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply.
Specialty Drugs
CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Benefit Explanation: Covers prescription legend drugs from either a Retail Pharmacy or the PBM’s Home Delivery Pharmacy; self-administered injectable drugs; specialty drugs; self-injectable insulin and supplies and equipment used to administer insulin; self-administered contraceptives, including oral contraceptive drugs, self-injectable contraceptive drugs, contraceptive patches, and contraceptive rings. Certain contraceptives are covered under the 'Preventive Care' benefit. Includes coverage for special food products or supplements when prescribed by a Doctor when medically necessary; Flu Shots (including administration). Inpatient or IV therapy drugs used in the treatment of cancer pain will not be denied on the basis that the dosage exceeds the recommended dosage of the pain relieving agent, if prescribed in compliance with established statutes pertaining to patients with intractable cancer pain. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30-day supply.
Inpatient Coverage
Hospital Services
CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Benefit Explanation: Benefits for room, board, and nursing services include: a room with two or more beds; a private room when medically necessary for isolation and no isolation facilities are available; a room in an approved special care unit; meals, special diets; general nursing services; operating, childbirth, and treatment rooms and equipment; prescribed drugs; anesthesia, anesthesia supplies and services given by the hospital or other provider; medical and surgical dressings and supplies, casts, and splints; blood and blood products; diagnostic services. Includes coverage for general anesthesia and hospitalization services when determined by dentist and treating physician that such services are required to effectively and safely provide dental care for (i) children under the age of 5, (ii) covered persons who are severely disabled, or (iii) covered persons who have a medical condition that requires admission to a hospital or Outpatient surgery facility.
Inpatient Services
CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Benefit Explanation: Includes medical care visits; intensive medical care when medically necessary; treatment for a health problem by a Doctor who is not your surgeon while you are in the Hospital for surgery; treatment by two or more Doctors during one Hospital stay when the nature or severity of your health problem calls for the skill of separate Doctors; a personal bedside exam by another Doctor when asked for by your Doctor; surgery and general anesthesia; professional charges to interpret diagnostic tests such as imaging, pathology reports, and cardiology. Surgeries and procedures to correct congenital abnormalities that cause functional impairment and congenital abnormalities in newborn children; other invasive procedures, such as angiogram, arteriogram, amniocentesis, tap or puncture of brain or spine; endoscopic exams, such as arthroscopy, bronchoscopy, colonoscopy, laparoscopy; treatment of fractures and dislocations; anesthesia and surgical support when medically necessary; medically necessary pre-operative and post-operative care. Medical benefits are limited to certain oral surgeries including: treatment of medically diagnosed cleft lip, cleft palate, or ectodermal dysplasia; maxillary or mandibular frenectomy when not related to a dental procedure; alveolectomy when related to tooth extraction; orthognathic surgery because of a medical condition or injury or for a physical abnormality that prevents normal function of the joint or bone and is medically necessary to attain functional capacity of the affected part; oral / surgical correction of accidental injuries; surgical services on the hard or soft tissue in the mouth when the main purpose is not to treat or help the teeth and their supporting structures; treatment of non-dental lesions, such as removal of tumors and biopsies; incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses. Includes surgical treatment of injuries and illnesses of the eye.
Emergency and Urgent Care
Emergency Room
CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Benefit Explanation: Benefits are available in a Hospital Emergency Room or an independent, free standing emergeny facility for services and supplies to treat the onset of symptoms for a medical emergency.
Urgent Care Facility
CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Exclusions: Non-plan providers are covered only outside the service area.
Benefit Explanation: Includes X-ray services; Care for broken bones; Tests such as flu, urinalysis, allergy test, pregnancy test, rapid strep; Lab services; Stitches for simple cuts; and Draining an abscess.
Maternity
Labor and Delivery Hospital Stay
CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Benefit Explanation: Includes services needed during a normal or complicated pregnancy and for services needed for a miscarriage. Covered maternity services include: pregnancy testing; professional and facility services for childbirth including use of the delivery room and care for normal deliveries, in a facility or the home including the services of an appropriately licensed nurse midwife; anesthesia services to provide partial or complete loss of sensation before delivery; routine nursery care for the newborn during the mother’s normal hospital stay, including circumcision of a covered male dependent; allowed fetal screenings, which are genetic or chromosomal tests of the fetus. Hospital stay for childbirth for mother and newborn may not be limited to less than 48 hours after vaginal birth or less than 96 hours after a cesarean section, unless the mother and attending provider request it.
Pre and Postnatal Office Visit
CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Benefit Explanation: Includes prenatal and postnatal services for the mother; postnatal services for the baby, including hemoglobinopathies screening; gonorrhea prophylactic medication; hypothyroidism screening, PKY screening and Rh incompatibility testing.
Vision
Routine Eye Exams For Children
CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Benefit Period
Benefit Explanation: Limited to one (1) eye exam per benefit period. Includes complete eye exam with dilation, as needed to check all aspects of vision, including the structure of the eyes and how well they work together.
Major Dental Care
Routine Dental Checkups for Children
CoPay: Not Applicable
CoInsurance: No Charge
Covered: Covered
Limit Quantity: 1
Limit Unit : Treatment(s) per 6 Months
Benefit Explanation: Limited to one (1) treatment(s) per 6 Months. Includes coverage for D1110, D1120, D1203, D1204, D1206, and D1208. $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
