Elite Gold + Vision + Adult Dental – EPO

Network type: EPO
Coverage tier: Gold
Primary care visit: $5 copay
Specialist visit: $60 copay
Urgent care visit: $35 copay

Description

Health Care Plan Details

Network type EPO
Deductible $0 per person $0 per person
Out-of-pocket max $5,500 per person $11,000 per family
Metal tier Gold

Visit Copay

Primary care visit $5 copay
Specialist visit $60 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $35 copay
Emergency room 30% coinsurance
Ambulance 30% coinsurance
Hospital stay (facility) 30% coinsurance
Hospital stay (physician) 30% coinsurance
Outpatient procedure (facility) $200 copay
Outpatient procedure (physician) $200 copay
Physical rehabilitation $50 copay

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay 30% coinsurance

Pharmacy, Drugs, and Medication

Generic $3 copay
Brand $50 copay
Non-preferred Brand 50% coinsurance
Specialty 50% coinsurance

Lab Tests and Diagnostic Procedures

X-rays $75 copay
Imaging (CT/PET/MRI) $75 copay
Blood work $40 copay

Mental and Psychiatric Health Care

Mental Health outpatient services $5 copay
Psychiatric hospital stay 30% coinsurance

Health Plan Provider Information

Health Plan Benefits https://api.centene.com/SBC/2024/90787LA0020008-01.pdf
Drug and medication plan formulary https://ambetter.louisianahealthconnect.com/resources/pharmacy-resources.html
Search doctor list https://ambetter.louisianahealthconnect.com/findadoc