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Return to plan selection tool| 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 |