Benefit Explanation: Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge.
Specialist
CoPay: $75.00
CoInsurance: Not Applicable
Covered: Covered
Prescription Drug Information
Preferred Brand Drugs
CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered
Non Preferred Brand Drugs
CoPay: $100.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Generic Drugs
CoPay: $10.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Prior authorization may be required - please contact the number listed on your ID card. 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: $250.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Inpatient Coverage
Hospital Services
CoPay: $1,000.00 Copay per Day after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Prior authorization may be required - please contact the number listed on your ID card.
Inpatient Services
CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Benefit Explanation: Prior authorization may be required - please contact the number listed on your ID card.
Emergency and Urgent Care
Emergency Room
CoPay: $250.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Urgent Care Facility
CoPay: $60.00
CoInsurance: Not Applicable
Covered: Covered
Maternity
Labor and Delivery Hospital Stay
CoPay: $1,000.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Prior authorization may be required - please contact the number listed on your ID card.
1-817-813-4562, TTY 711
