Benefit Explanation: Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge.
Specialist
CoPay: $70.00
CoInsurance: Not Applicable
Covered: Covered
Prescription Drug Information
Preferred Brand Drugs
CoPay: $60.00
CoInsurance: Not Applicable
Covered: Covered
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Generic Drugs
CoPay: $22.60
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: 50.00% Coinsurance after deductible
Covered: Covered
Inpatient Coverage
Hospital Services
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance 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: 40.00% Coinsurance 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: 40.00% Coinsurance after deductible
Covered: Covered
Urgent Care Facility
CoPay: $55.00
CoInsurance: Not Applicable
Covered: Covered
Maternity
Labor and Delivery Hospital Stay
CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Prior authorization may be required - please contact the number listed on your ID card.
1-817-813-4562, TTY 711
