Benefit Explanation: Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge.
Specialist
CoPay: $30.00
CoInsurance: Not Applicable
Covered: Covered
Prescription Drug Information
Preferred Brand Drugs
CoPay: $30.00
CoInsurance: Not Applicable
Covered: Covered
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Generic Drugs
CoPay: $13.80
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: 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: 30.00% Coinsurance after deductible
Covered: Covered
Inpatient Coverage
Hospital Services
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Inpatient Services
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Note: Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization.
1-817-813-4562, TTY 711
