Benefit Explanation: Unlimited Primary Care Virtual Visits received from Ambetter Telehealth covered at No Charge. Primary Virtual Care Visits are only availble for adult members (18 years of age and older).
Specialist
CoPay: $45.00
CoInsurance: Not Applicable
Covered: Covered
Prescription Drug Information
Preferred Brand Drugs
CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 25.00% 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: 25.00% Coinsurance after deductible
Covered: Covered
Inpatient Coverage
Hospital Services
CoPay: Not Applicable
CoInsurance: 25.00% Coinsurance after deductible
Covered: Covered
Inpatient Services
CoPay: Not Applicable
CoInsurance: 25.00% Coinsurance after deductible
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: Not Applicable
CoInsurance: 25.00% Coinsurance after deductible
Covered: Covered
Urgent Care Facility
CoPay: $30.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge.
1-817-813-4562, TTY 711
