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