AultCare Silver 7900 Premier Select – PPO

Description

Health Care Plan Details

Network type	PPO
Deductible	$7,900 per person $7,900 per person
Out-of-pocket max	$9,350 per person $18,700 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=SBC61052024.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