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/2024/70111TN0120034-01.pdf |
| Drug and medication plan formulary | https://ambetteroftennessee.com/resources/pharmacy-resources.html |
| Search doctor list | https://www.ambetteroftennessee.com/findadoc |
