Benefit Explanation: In-network: Virtual care visits $50 copay; in-person visits $100 copay. For Zero Cost Sharing plans: Virtual care and in-person visits $0 copay.
Prescription Drug Information
Preferred Brand Drugs
CoPay: $50.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $25 for a 30-day supply. Known as the Preferred tier in the plan, and it includes generic medications that have no more favorable outcomes, from a clinical perspective, than other more cost effective generic medications .
Non Preferred Brand Drugs
CoPay: $100.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $25 for a 30-day supply. Known as the Non-preferred tier in the plan, and these medications do not have significant therapeutic advantage over their preferred alternatives. These products generally have safe and effective options available under the Value, Select and/or Preferred tiers.
Generic Drugs
CoPay: $25.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Retail up to 30-day supply and mail order up to 90-day supply per prescription. Insulin member cost share maximum of $25 for a 30-day supply. Known as the Select tier in the plan, and it includes generic medications that represent the most cost effective option, as well as certain cost effective brand medications.
Specialty Drugs
CoPay: $500.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Up to 30-day supply per prescription at designated specialty pharmacies only. Non-Preferred Specialty tier may have higher cost sharing.
Inpatient Coverage
Hospital Services
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: All usual hospital services and supplies, including semiprivate room, intensive care, and coronary care units; Prior authorization is required.
Inpatient Services
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Urgent Care Facility
CoPay: $75.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: In-network: Virtual care visits $50 copay via CirrusMD; in-person visits $75 copay. For Zero Cost Sharing plans: Virtual care and in-person visits $0 copay.
Maternity
Labor and Delivery Hospital Stay
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated caesarean section.
Pre and Postnatal Office Visit
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Vision
Routine Eye Exams for Children
CoPay: $0.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: 1 exam per year for members through the end of the month in which they reach age 19.
1-817-813-4562, TTY 711
