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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 andTherapeutic 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 |