Elite Gold
Ambetter from Arizona Complete Health
Plan overview
Medical deductible
Individual: $0
Family: $0
Per Person: $0
Prescription drug deductible
Individual: $0
Family: $0
Per Person: $0
Combined medical and drug out of pocket maximum
Individual: $6500
Family: $13000
Per Person: $6500
Office visit
Primary Doctor
CoPay: $5.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Unlimited Virtual 24/7 Care Visits received from Ambetter’s designated telehealth provider covered at No Charge, except for HSAs. Primary care visits provided to treat a behavioral health diagnosis fall under mental/behavioral health services.
Specialist
CoPay: $60.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Specialist visits provided to treat a behavioral health diagnosis fall under mental/behavioral health services.
Prescription drug information
Preferred brand drugs
CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
Non preferred brand drugs
CoPay: Not Applicable
CoInsurance: 45.00%
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
Generic drugs
CoPay: $3.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Cost sharing shown applies to Tier 1a-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 1b-Generic Drugs, which may apply a higher cost share. Up to a 30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. Refer to the prescription drug list for more information.
Specialty drugs
CoPay: Not Applicable
CoInsurance: 50.00%
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
Inpatient coverage
Hospital services
CoPay: Not Applicable
CoInsurance: 30.00%
Covered: Covered
Inpatient services
CoPay: Not Applicable
CoInsurance: 30.00%
Covered: Covered
Emergency and urgent care
Emergency room
CoPay: Not Applicable
CoInsurance: 30.00%
Covered: Covered
Urgent care facility
CoPay: $35.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation:
Maternity
Labor and delivery hospital stay
CoPay: Not Applicable
CoInsurance: 30.00%
Covered: Covered
Pre and Postnatal office visit
CoPay: $5.00
CoInsurance: Not Applicable
Covered: Covered
Vision
Routine Eye Exams for Children
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit: Exam(s) per Year
Major dental care
Routine dental checkups for children
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Routine dental checkups for adults
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
These policies have exclusions, limitations, reduction of benefits, terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable).