Office Visits (other than Preventive Care Services) This plan covers office and clinic visits to diagnose or treat a sickness or injury. Office visit copayments differ depending on the type of provider you see. This plan covers physician visits in your home if you have an injury or illness that: • confines you to your home; or • requires special transportation; and • because of this injury or illness, you are physically unable to travel to the provider’s
Preventive Care and Early Detection Services This plan covers, early detection services, preventive care services, and immunizations or vaccinations in accordance with state and federal law, including the Affordable Care Act (ACA), as set forth below and in accordance with the guidelines of the following resources: • services that have an A or B rating in the current recommendations of the U.S. Preventative Services Task Force (USPSTF); • immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; • preventive care and screenings for infants, children, and adolescents as outlined in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA); or • preventive care and screenings for women as outlined in the comprehensive guidelines as supported by HRSA. Covered early detection services, preventive care services and adult and pediatric immunizations or vaccinations are based on the most currently available guidelines and are subject to change. The amount you pay for preventive services will be different from the amount you pay for diagnostic procedures and non-preventive services. See the Summary of Medical Benefits and the Summary of Pharmacy Benefits for more information about the amount you pay. This plan covers the following preventive office visits. • Annual preventive visit - one (1) routine physical examination per plan year per • Pediatric preventive office and clinic visits from birth to 35 months - 11 visits; • Well Woman annual preventive visit - one (1) routine gynecological examination per plan year per female member.
Preventive Drugs When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. $0 Not Covered Nicotine Replacement Therapy (NRT) and Smoking Cessation Prescription Drugs When purchased at any pharmacy: Must be prescribed by a physician. See Prescription Drug section for details. Tier 1 Preventive: $0 Tier 1 Non-preventive: $10 - After deductible Not Covered Tier 2 Preventive: $0 Tier 2 Non-preventive: $45 - After deductible Not Covered Tier 3: $70 - After deductible Not Covered Tier 4: $90 - After deductible Not Covered Tier 5: NRT and Smoking Cessation drugs are only placed in Tier 1, Tier 2, Tier 3, or Tier 4. See above. Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered
Specialty Prescription Drugs (+ Prorated copayments for a shorter supply period may apply for network pharmacy only. See Prescription Drug section for details. When purchased at a Specialty Pharmacy (+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribed dosing period. Tier 5: $125 Not Covered When purchased at a Retail Pharmacy (+): For maintenance and non-maintenance prescription drugs, a copayment applies for each 30-day period (or portion thereof) within the prescribed dosing period. Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a Specialty Pharmacy. Our reimbursement is based on the pharmacy allowance. Tier 5: 50% Not Covered When purchased at a Mail Order Pharmacy: Not Covered Not Covered (+) Preauthorization is required for this service. Please see Preauthorization in Section 3 for more information. You Pay You Pay Infertility Prescription Drugs - Three (3) in-vitro cycles will be covered per plan year with a total of eight (8) in-vitro cycles covered in a member’s lifetime. When purchased at a Specialty, Mail Order, or Retail Pharmacy Tier 1: 20% Not Covered Tier 2: 20% Not Covered Tier 3: 20% Not Covered Tier 4: 20% Not Covered When purchased at a Specialty Pharmacy (+) Tier 5: 20% Not Covered When purchased at a Retail Pharmacy (+): Specialty Prescription Drugs purchased at a retail pharmacy will require a significantly higher out of pocket expense than if purchased from a specialty pharmacy. Tier 5: 20% Not Covered Contraceptive Methods - Preventive Coverage includes barrier method (diaphragm or cervical cap), hormonal method (birth control pill), and emergency contraception. For non-preventive contraceptive prescription drugs and devices, the amount you pay will depend on the tier placement of the contraceptive prescription drug or device. See above for details. When purchased at a Retail Pharmacy: Up to a 365-day supply of contraceptive prescription drugs is available at all network retail pharmacies. For more information about this option, visit our website. Tier 1: $0 Not Covered When purchased at a Mail Order Pharmacy: Up to a 90-day supply. Tier 1: $0 Not Covered
