Connected Silver + Vision + Adult Dental – PPO
Network type: PPO
Coverage tier: Silver
Primary care visit: $55 copay
Specialist visit: $75 copay
Urgent care visit: $60 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $7,350 per person $7,350 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $55 copay |
| Specialist visit | $75 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $60 copay |
| Emergency room | $250 copay after deductible |
| Ambulance | $750 copay after deductible |
| Hospital stay (facility) | $1,000 copay per Day after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | $250 copay after deductible |
| Outpatient procedure (physician) | $100 copay after deductible |
| Physical rehabilitation | $50 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | $1000 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $15 copay |
| Brand | $50 copay |
| Non-preferred Brand | $100 copay after deductible |
| Specialty | $250 copay after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $60 copay |
| Imaging (CT/PET/MRI) | $150 copay |
| Blood work | $60 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $55 copay |
| Psychiatric hospital stay | $1,000 copay per Day after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://api.centene.com/SBC/2024/62141AR0100007-01.pdf |
| Drug and medication plan formulary | https://ambetter.arhealthwellness.com/resources/pharmacy-resources.html |
| Search doctor list | https://ambetter.arhealthwellness.com/findadoc |
