AultCare Silver 7900 Premier Select – PPO
73% cost sharing reduction [Popular Plan]
Network type: PPO
Coverage tier: Silver
Primary care visit: $10 copay after deductible
Specialist visit: 25% coinsurance after deductible
Urgent care visit: $75 copay
Description
This plan has 73% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | PPO |
| Deductible | $4,900 per person $4,900 per person |
| Out-of-pocket max | $7,550 per person $15,100 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $10 copay after deductible |
| Specialist visit | 25% coinsurance after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay |
| Emergency room | $450 copay |
| Ambulance | 25% coinsurance after deductible |
| Hospital stay (facility) | $500 copay per Stay after deductible |
| Hospital stay (physician) | 25% coinsurance after deductible |
| Outpatient procedure (facility) | 25% coinsurance after deductible |
| Outpatient procedure (physician) | 25% coinsurance after deductible |
| Physical rehabilitation | 25% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $500 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $10 copay |
| Brand | 30% coinsurance |
| Non-preferred Brand | 25% coinsurance after deductible |
| Specialty | 25% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 25% coinsurance after deductible |
| Imaging (CT/PET/MRI) | 25% coinsurance after deductible |
| Blood work | 25% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 25% coinsurance after deductible |
| Psychiatric hospital stay | $500 copay per Stay after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://sso.aultcare.com/z/f/api/file/CMS/document?filename=SBC6105042024.pdf |
| Drug and medication plan formulary | https://sso.aultcare.com/z/f/api/file/CMS/document?filename=acformulary2024A.pdf |
| Search doctor list | https://directory.aultcare.com/directory/Prem-Sel |
