Prescription Drug Program
Retail Copay Generic: $5.00
Retail Copay Regular: $20.00
Retail Copay High Cost Drugs: $35.00
This cost is based on a monthly basis therefore if you purchase a
three month supply you will pay $15.00 for generic drugs, $60.00 for
regular drugs and $105.00 for high cost drugs.
Mail In Copay Generic: $10.00
Mail In Copay Regular: $40.00
Mail in Copay High Cost Drugs: $70.00
This is the cost for a 3 months supply. Therefore, basically you buy
2 and get 1 for free.
Dental Program
Diagnostic and Preventive Care – 100% (2 free cleanings each
year)
Basic Care – 80% (emergency pain relief, extractions, oral surgery,
fillings, general anesthesia, treatment of disease of gums or
related tissue, treatment of tooth pulp, including root canal
therapy and pulp vitality test, injection of antibiotic drugs,
repair of recementation of crowns, inlays, onlays, bridgework or
dentures.)
Major Care – 50% (inlays, onlays, crowns and other Gold and baked
porcelain restorations, initial installation of bridgework, initial
installation of partial and full removable dentures, replacement of
existing partial, full removable dentures, fixed bridgework by a new
denture or new bridgework, the addition of teeth to an existing
partial removable denture or bridgework.)
Orthodontic Care – 50% with a limiting age of 19. Maximum lifetime
benefits - $1000.00
Eye Exams
Pay $20.00 copay to receive eye exam from a Blue Cross Blue
Shield provider.
Eye Glasses or contacts are totally up to you.
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