Tier 4 - Typically Preferred Specialty (brand and generic) 20% coinsurance 30% coinsurance You pay additional copays or coinsurance on all tiers for retail fills that exceed 30 days. after deductible is after deductible is Covers up to a 30 day supply (retail pharmacy). Covers up to 30 day supply (home delivery met(retail and home met(retail and home program.) Note: Coverage is also provided at retail for up to a 12-month supply of delivery). delivery). self-administered hormonal contraceptives, when dispensed or furnished at one time. No coverage for non-formulary drugs. Cost if you use an Cost if you use a Covered Vision Benefits In-Network Non-Network Provider Provider This is a brief outline of your vision coverage. Not all cost shares for covered services are shown below. For a full list, including benefits, exclusions and limitations, see the combined Evidence of Coverage/Disclosure form/Certificate. If there is a difference between this summary and either Evidence of Coverage/Disclosure form/Certificate, the Evidence of Coverage/Disclosure form/Certificate will prevail. Child Vision exam No charge $30 reimbursement Coverage for In-Network Providers is limited to 1 exam per benefit period. Adult Vision exam $15 copay per visit $30 reimbursement Coverage for In-Network Providers is limited to 1 exam per benefit period.
Tier 4 - Typically Preferred Specialty (brand and generic) You pay additional copays or coinsurance on all tiers for retail fills that exceed 30 days. Covers up to a 30 day supply (retail pharmacy). Covers up to 30 day supply (home delivery program.) Note: Coverage is also provided at retail for up to a 12-month supply of self-administered hormonal contraceptives, when dispensed or furnished at one time. No coverage for non-formulary drugs. 20% coinsurance after deductible is met(retail and home delivery). 30% coinsurance after deductible is met(retail and home delivery). Covered Vision Benefits Cost if you use an In-Network Provider Cost if you use a Non-Network Provider This is a brief outline of your vision coverage. Not all cost shares for covered services are shown below. For a full list, including benefits, exclusions and limitations, see the combined Evidence of Coverage/Disclosure form/Certificate. If there is a difference between this summary and either Evidence of Coverage/Disclosure form/Certificate, the Evidence of Coverage/Disclosure form/Certificate will prevail. Child Vision exam Coverage for In-Network Providers is limited to 1 exam per benefit period. No charge $30 reimbursement Adult Vision exam Coverage for In-Network Providers is limited to 1 exam per benefit period. $15 copay per visit $30 reimbursement