Connected Silver (QualChoiceLife) – 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/2024/37903AR0070025-01.pdf |
Drug and medication plan formulary | https://ambetter.arhealthwellness.com/resources/pharmacy-resources.html |
Search doctor list | https://ambetter.arhealthwellness.com/findadoc |