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Covered Services
Monthly Premium
Primary Care Doctor Copay
Specialist Copay
Annual Wellness Visit
Telehealth Benefit
Preventive Health Screenings
Inpatient Hospital Care
Skilled Nursing Facility Care (SNF)
Outpatient Diagnostic Test and
Therapeutic Services & Supplies
Emergency Care
Ambulance Services
Urgently Needed Services
Convenient Care
Over-the-Counter Items (OTC)
Outpatient Hospital Observation
Outpatient Surgery
Prescription Drugs: Preferred Retail Cost-Sharing - 30 / 60 / 90 day supply
Tier 1 (standard Generic)
Tier 2 (Generic)
Tier 3 (standard Brand)
Select Insulins
Tier 4 (Non-standard Drug)
Tier 5 (Specialty Tier)
Prescription Drugs: Standard Retail Cost-Sharing - 30 / 60 / 90 day supply
Tier 1 (standard Generic)
Tier 2 (Generic)
Tier 3 (standard Brand)
Select Insulins
Tier 4 (Non-standard Drug)
Tier 5 (Specialty Tier)
Other Benefits
Mail Order
Insulin Savings Model
Coverage Stages
Deductible Stage
Initial Coverage Stage
Coverage Gap Stage
Catastrophic Coverage Stage
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