AultCare Silver 6850 Select No Pediatric Dental – PPO
Network type: PPO
Coverage tier: Silver
Primary care visit: $10 copay after deductible
Specialist visit: $25 copay after deductible
Urgent care visit: $75 copay
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $6,850 per person $6,850 per person |
| Out-of-pocket max | $6,850 per person $13,700 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $10 copay after deductible |
| Specialist visit | $25 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay |
| Emergency room | No charge after deductible |
| Ambulance | No charge after deductible |
| Hospital stay (facility) | No charge after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | No charge after deductible |
| Outpatient procedure (physician) | No charge after deductible |
| Physical rehabilitation | No charge after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | No charge after deductible |
Pharmacy, Drugs, and Medication
| Generic | $10 copay |
| Brand | 30% coinsurance |
| Non-preferred Brand | No charge after deductible |
| Specialty | No charge after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | No charge after deductible |
| Imaging (CT/PET/MRI) | No charge after deductible |
| Blood work | No charge after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | No charge after deductible |
| Psychiatric hospital stay | No charge after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://sso.aultcare.com/z/f/api/file/CMS/document?filename=SBC6742024.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/SELECT-PPO |
