Benefit Explanation: Bronze Essential first 4 PCP, Specialists, Urgent Care office visits combined per calendar year; are not subject to the deductible for in-network providers
Specialist
CoPay: $60.00 Copay with deductible
CoInsurance: 10.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Bronze Essential first 4 PCP, Specialists, Urgent Care office visits combined per calendar year; are not subject to the deductible for in-network providers
Prescription Drug Information
Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: insulin limit of $28 per 30 days $84 for 90 day supply
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: insulin limit of $28 per 30 days $84 for 90 day supply
Generic Drugs
CoPay: $15.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: insulin limit of $28 per 30 days $84 for 90 day supply
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: First fill allowed at a retail pharmacy. Insulin limit of $28 per 30 days, $84 for 90 day-supply
Inpatient Coverage
Hospital Services
CoPay: Not Applicable
CoInsurance: 10.00% Coinsurance after deductible
Covered: Covered
Inpatient Services
CoPay: Not Applicable
CoInsurance: 10.00% Coinsurance after deductible
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: Not Applicable
CoInsurance: 10.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Out of service area coverage is available.
Urgent Care Facility
CoPay: $60.00 Copay with deductible
CoInsurance: 10.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Bronze Essential first 4 PCP, Specialists, Urgent Care office visits combined per calendar year; are not subject to the deductible for in-network providers