Everyday Gold + Vision + Adult Dental – PPO

Network type: PPO
Coverage tier: Gold
Primary care visit: $35 copay
Specialist visit: $55 copay
Urgent care visit: $35 copay

SKU: 62505OK0130014 Categories: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

Description

Health Care Plan Details

Network type PPO
Deductible $750 per person $750 per person
Out-of-pocket max $7,500 per person $15,000 per family
Metal tier Gold

Visit Copay

Primary care visit $35 copay
Specialist visit $55 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

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

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay 35% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic $3 copay
Brand $60 copay
Non-preferred Brand 50% coinsurance after deductible
Specialty 50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays 35% coinsurance after deductible
Imaging (CT/PET/MRI) 35% coinsurance after deductible
Blood work $35 copay

Mental and Psychiatric Health Care

Mental Health outpatient services $35 copay
Psychiatric hospital stay 35% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://api.centene.com/SBC/2024/62505OK0130014-01.pdf
Drug and medication plan formulary https://ambetterofoklahoma.com/resources/pharmacy-resources.html
Search doctor list https://www.ambetterofoklahoma.com/findadoc