Benefit Explanation: Copay applies to the first 4 medical office visits per member (not exceed 8 medical office visits per family). Deductible and coinsurance applies after the first 4 medical office visits per member or 8 medical office visits per family.
Specialist
CoPay: $80.00 Copay with deductible
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Copay applies to the first 4 medical office visits per member (not exceed 8 medical office visits per family). Deductible and coinsurance applies after the first 4 medical office visits per member or 8 medical office visits per family.
Prescription Drug Information
Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 35.00% Coinsurance after deductible
Covered: Covered
Generic Drugs
CoPay: $10.00
CoInsurance: Not Applicable
Covered: Covered
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Exclusions: Specialty Drugs purchased through non-contracted or non-specialty drug pharmacies will not be covered.
Inpatient Coverage
Hospital Services
CoPay: $500.00 Copay per Stay after deductible
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Inpatient Services
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: $500.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Urgent Care Facility
CoPay: $50.00 Copay with deductible
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Copay applies to the first 4 medical office visits per member (not exceed 8 medical office visits per family). Deductible and coinsurance applies after the first 4 medical office visits per member or 8 medical office visits per family.
Maternity
Labor and Delivery Hospital Stay
CoPay: $500.00 Copay after deductible
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Pre and Postnatal Office Visit
CoPay: No Charge
CoInsurance: No Charge
Covered: Covered
Benefit Explanation: Routine Prenatal and Postnatal Care are covered in full.
Vision
Routine Eye Exams For Children
CoPay: $40.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year
Benefit Explanation: For Members under the age of 19