Ambetter from MHS

Elite Gold + Vision + Adult Dental

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $0.00 Family: $0 Per Person: $0
Combined Medical and Drug Out of Pocket Maximum	Individual: $5,500.00 Family: $11000 Per Person: $5500

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.
Specialist	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 45.00% Covered: Covered
Generic Drugs	CoPay: $3.00 CoInsurance: Not Applicable Covered: Covered 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

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 30.00% Covered: Covered Benefit Explanation: Maximum 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). Limit is combined both In and Out of Network.
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

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 : Visit(s) per Year

Major Dental Care

Routine Dental Checkups for Children	Covered: Not Covered
Routine Dental Checkups for Adults	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered Limit Quantity: 1000 Limit Unit : Dollars per Year Benefit Explanation: $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults