Benefit Explanation: Your Prescription Drug benefits may include a Formulary ... which is a list of Brand Name Prescription Drugs that are preferred by your Plan. We may remind your Physician or Professional Other Provider when a Formulary medication is available for a medication that is not on your Formulary. This may result in a change in your Prescription. However, your Physician or Professional Other Provider will always make the final decision on your medication.
Generic Drugs
CoPay: $3.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Select Healthy Heart Drugs and Supplies are covered at no charge. Refer to the plan brochure for more information.
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Inpatient Coverage
Hospital Services
CoPay: $250.00 Copay per Stay after deductible
CoInsurance: Not Applicable
Covered: Covered
Inpatient Services
CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Emergency room copay or coinsurance is waived if you are admitted to the hospital directly from the Emergency Department.
1-817-813-4562, TTY 711
