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Ambetter of Arkansas

Ambetter Balanced Care 4

Plan Overview

Combined Medical and Drug Deductible
  • Individual: $7,200.00
  • Family: $14,400
  • Per Person: $7,200
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $7,200.00
  • Family: $14,400
  • Per Person: $7,200

Office Visit

Primary Doctor
  • CoPay: $30.00
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge.
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: No Charge after deductible
  • Covered: Covered
Generic Drugs
  • CoPay: $13.80
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Prior authorization may be required - please contact the number listed on your ID card. Most Ambetter Plans offer Preferred Generic Drugs at $5 or less. Please see plan's Summary of Benefits and Coverage (SBC) or policy document for Preferred Generic and Generic prescription drug cost.
Specialty Drugs
  • CoPay: Not Applicable
  • CoInsurance: No Charge after deductible
  • Covered: Covered

Inpatient Coverage

Hospital Services
  • CoPay: Not Applicable
  • CoInsurance: No Charge after deductible
  • Covered: Covered
  • Benefit Explanation: Prior authorization may be required - please contact the number listed on your ID card.
Inpatient Services
  • CoPay: Not Applicable
  • CoInsurance: No Charge after deductible
  • Covered: Covered
  • Benefit Explanation: Prior authorization may be required - please contact the number listed on your ID card.

Emergency and Urgent Care

Emergency Room
  • CoPay: Not Applicable
  • CoInsurance: No Charge after deductible
  • Covered: Covered
Urgent Care Facility
  • CoPay: $60.00
  • CoInsurance: Not Applicable
  • Covered: Covered

Maternity

Labor and Delivery Hospital Stay
  • CoPay: Not Applicable
  • CoInsurance: No Charge after deductible
  • Covered: Covered
  • Benefit Explanation: Prior authorization may be required - please contact the number listed on your ID card.
Pre and Postnatal Office Visit
  • CoPay: $30.00
  • 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
  • Benefit Explanation: Up to $38.50 OON

Major Dental Care

Routine Dental Checkups for Children
  • Covered: Not Covered
Routine Dental Checkups for Adults
  • Covered: Not Covered
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