|Preventive Care||Paid at 100% of maximum allowable amount at appropriate intervals when services are rendered by a network provider.|
|Primary Care |
|Prescription Drugs |
|Tier 1: Generic Drugs||$25|
|Tier 2: Preferred Brand drugs||$50 copay subject to deductible|
|Summary of Benefits and Coverage (SBC)|| |
*This plan does not include kid’s dental coverage.
At-a-Glance is intended to be a condensed overview of some plan benefits and does not cover all benefits or information contained in the Benefit Booklet. Limitations and exclusions do exist. At-a-Glance is not a contract. For exact benefits and limitations, please request a copy of the Benefit Booklet.
Based on certain income requirements, you may qualify for assistance, through government subsidies, with your monthly premiums.
Find important information on your prescriptions, including how to select a pharmacy, request prescription benefits, and more.