Benefit Explanation: The first 2 visits to a designated primary care provider (PCP) are covered in full. Subsequent visits are subject to the PCP copay.
Specialist
CoPay: $60.00
CoInsurance: Not Applicable
Covered: Covered
Prescription Drug Information
Preferred Brand Drugs
CoPay: $45.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 90
Limit Unit : Item(s) per Month
Benefit Explanation: Up to 90 day supply Retail (copay times 3); 90 day supply for Mail order.
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Limit Quantity: 90
Limit Unit : Item(s) per Month
Benefit Explanation: Up to 90 day supply Retail (copay times 3); 90 day supply for Mail order. This tier contains all non-preferred drugs.
Generic Drugs
CoPay: $15.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 90
Limit Unit : Item(s) per Month
Benefit Explanation: Up to 90 day supply Retail (copay times 3); 90 day supply for Mail order. This tier contains only Preferred Generic drugs.
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Limit Quantity: 30
Limit Unit : Item(s) per Month
Benefit Explanation: 30 day supply Retail and Mail
Inpatient Coverage
Hospital Services
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Inpatient Services
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: Not Applicable
CoInsurance: 30.00% 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: 30.00% Coinsurance after deductible
Covered: Covered
Pre and Postnatal Office Visit
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Vision
Routine Eye Exams For Children
CoPay: $30.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year
Benefit Explanation: Under age 19, 1 PCY; Over age 19 Not Covered
Major Dental Care
Routine Dental Checkups for Children
CoPay: $0.00
CoInsurance: 0.00%
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per 6 Months
Routine Dental Checkups for Adults
CoPay: Not Applicable
CoInsurance: 10.00%
Covered: Covered
Limit Quantity: 2
Limit Unit : Exam(s) per Year
Benefit Explanation: Routine Exam - 2 PCY and Cleanings- 2 PCY; Routine X-rays (bitewing) - 1 PCY; Annual maximum of $750 PCY
1-817-813-4562, TTY 711
