Benefit Explanation: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill.
Non Preferred Brand Drugs
CoPay: $250.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 30
Limit Unit : Days per Month
Benefit Explanation: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill.
Generic Drugs
CoPay: $20.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 30
Limit Unit : Days per Month
Benefit Explanation: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. 53732WA0790024 both WAF010, WAF013 apply; 53732WA0790025 both WAF017, WAF014 apply; 53732WA0790026 both WAF018, WAF015 apply
Specialty Drugs
CoPay: $250.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 30
Limit Unit : Days per Month
Benefit Explanation: First fill allowed at a retail pharmacy. Additional fills must be provided at a specialty pharmacy. Coverage is limited to a 30-day supply for specialty and self-administrable cancer chemotherapy medications from a specialty pharmacy per fill or refill.
Inpatient Coverage
Hospital Services
CoPay: $800.00 Copay per Day after deductible
CoInsurance: Not Applicable
Covered: Covered
Inpatient Services
CoPay: $800.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: $800.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Out of service area coverage is available.