VAULT Captive V2500
$0.00
SKU
VAULT Captive V2500
- Preventive services
- Labs imaging, hospitalization and surgery, preferred formulary prescription coverage, unlimited $0 telehealth consults
Summary of Benefits
General provisions
Deductible (combined with pharmacy benefit)
$2,500(Individual), $5,000 (Family)
Benefit percentage (after satisfaction of deductible/out of pocket maximum)
100%
Out of pocket maximum (patient responsibility for pharmacy co-pay and co-insurance continues after reaching out of pocket maximum.) See pharmacy tiers below
$2,500(Individual), $5,000 (Family)
Pharmacy
Tier
Retail Copayment (Maximum 30 day supply)
Mail order-copayment (Maximum 90 day supply)
Tier 1 : Preventative drugs
$0.00 (Prior to and after meeting the deductible)
$0.00 (Prior to and after meeting the deductible)
Tier 2 : Preferred generics
100% prior to meeting deductible, $15.00 (after deductible)
100% prior to meeting deductible, $30.00 (after deductible)
Tier 3 : Preferred Brand & non- referred generics
100% prior to meeting deductible, $50.00 (after deductible)
100% prior to meeting deductible, $100.00 (after deductible)
Tier 4 : Non-Preferred Brand
100% prior to meeting deductible, $100.00 (after deductible)
100% prior to meeting deductible, $200.00 (after deductible)
Tier 5 : Specialty drugs
100% prior to meeting deductible
35% copayment after meeting deductible
Max 30 day supply
35% copayment after meeting deductible
Max 30 day supply
Tier 6 : Non-formulary & excluded drugs
100% copay - not covered
Please Note:
Please refer to the schedule of benefits and description of coverage for the official list of benefits coverage, limitations, and exclusions. if plan comparison above differs from the schedule of benefits and description of coverage, the schedule of benefits and description of coverage will govern.
