Benefit Explanation: Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge, except for HSAs.
Specialist
CoPay: $35.00
CoInsurance: Not Applicable
Covered: Covered
Prescription Drug Information
Preferred Brand Drugs
CoPay: $30.00
CoInsurance: Not Applicable
Covered: Covered
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Generic Drugs
CoPay: $13.80
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Most Ambetter Plans offer Preferred Generic Drugs at $5 or less. Please see plan's Summary of Benefits and Coverage (SBC) or policy document for Preferred Generic and Generic prescription drug cost.
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Inpatient Coverage
Hospital Services
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Inpatient Services
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Urgent Care Facility
CoPay: $35.00
CoInsurance: Not Applicable
Covered: Covered
Maternity
Labor and Delivery Hospital Stay
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Newborn benefits do not apply to the newly born child of an Eligible Dependent daughter unless placement with the Employee is confirmed through a court order or legal guardianship.
Pre and Postnatal Office Visit
CoPay: $15.00
CoInsurance: Not Applicable
Covered: Covered
Vision
Routine Eye Exams For Children
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per Year
Major Dental Care
Routine Dental Checkups for Children
Covered: Not Covered
Routine Dental Checkups for Adults
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1000
Limit Unit : Dollars per Year
Benefit Explanation: $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults
1-817-813-4562, TTY 711
