Standard Gold + Vision + Adult Dental – HMO

Network type: HMO
Coverage tier: Gold
Primary care visit: $30 copay
Specialist visit: $60 copay
Urgent care visit: $45 copay

SKU: 79222SC0020033 Categories: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

Description

Health Care Plan Details

Network type HMO
Deductible $1,500 per person $1,500 per person
Out-of-pocket max $8,700 per person $17,400 per family
Metal tier Gold

Visit Copay

Primary care visit $30 copay
Specialist visit $60 copay
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care $45 copay
Emergency room 25% coinsurance after deductible
Ambulance 25% coinsurance after deductible
Hospital stay (facility) 25% coinsurance 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 $30 copay

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay 25% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic $15 copay
Brand $30 copay
Non-preferred Brand $60 copay
Specialty $250 copay

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 $30 copay
Psychiatric hospital stay 25% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://api.centene.com/SBC/2024/79222SC0020033-01.pdf
Drug and medication plan formulary https://ambetter.absolutetotalcare.com/resources/pharmacy-resources.html
Search doctor list https://ambetter.absolutetotalcare.com/findadoc