Complete Silver + Vision + Adult Dental

62505OK0130007
Silver
PPO

Complete Silver + Vision + Adult Dental is a Silver PPO plan by Ambetter of Oklahoma.

IMPORTANT: You are viewing the 2023 version of Complete Silver + Vision + Adult Dental 62505OK0130007. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Complete Silver + Vision + Adult Dental is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Complete Silver + Vision + Adult Dental 62505OK0130007.
Insurer: Ambetter of Oklahoma
Network Type: PPO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 62505OK0130007

Cost-Sharing Overview

Complete Silver + Vision + Adult Dental offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Complete Silver + Vision + Adult Dental?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Complete Silver + Vision + Adult Dental offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Diabetes, Pregnancy
Notice Pregnancy: Yes
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Complete Silver + Vision + Adult Dental covers when you are out of the service area or out of the country.

Out of Country Coverage: No
Out of Country Coverage Description:
Out of Service Area Coverage: No
Out of Service Area Coverage Description:
National Network: No

Additional Benefits and Cost-Sharing

Complete Silver + Vision + Adult Dental includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$30.00 60.00% Coinsurance after deductible Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge.
Specialist Visit
Covered
$60.00 60.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$30.00 60.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Hospice Services
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Routine Dental Services (Adult)
Covered
No Charge No Charge $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults; excluded from the in-network MOOP
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible85 Visit(s) per Benefit Period Pre-authorization required.
Routine Eye Exam (Adult)
Covered
No Charge No Charge 1 Exam(s) per Year Up to $38.50 OON
Urgent Care Centers or Facilities
Covered
$60.00 60.00%
Home Health Care Services
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible30 Visit(s) per Benefit Period
Emergency Room Services
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Bariatric Surgery
Cosmetic Surgery
Skilled Nursing Facility
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible30 Days per Benefit Period
Prenatal and Postnatal Care
Covered
$30.00 60.00% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services
Covered
$30.00 60.00% Coinsurance after deductible Benefits for the treatment of Mental Illness include treatments for drug addiction, substance abuse and alcoholism.
Mental/Behavioral Health Inpatient Services
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible Benefits for the treatment of Mental Illness include treatments for drug addiction, substance abuse and alcoholism.
Substance Abuse Disorder Outpatient Services
Covered
$30.00 60.00% Coinsurance after deductible Benefits for the treatment of Mental Illness include treatments for drug addiction, substance abuse and alcoholism.
Substance Abuse Disorder Inpatient Services
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible Benefits for the treatment of Mental Illness include treatments for drug addiction, substance abuse and alcoholism.
Generic Drugs
Covered
$18.20 100.00% 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.
Preferred Brand Drugs
Covered
$55.00 100.00%
Non-Preferred Brand Drugs
Covered
50.00% Coinsurance after deductible 100.00%
Specialty Drugs
Covered
50.00% Coinsurance after deductible 100.00%
Outpatient Rehabilitation Services
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible30 Days per Benefit Period
Habilitation Services
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible25 Visit(s) per Benefit Period
Chiropractic Care
Covered
$60.00 60.00% Coinsurance after deductible
Durable Medical Equipment
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Hearing Aids
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible One hearing aid per ear every 48 months up to age 18.
Imaging (CT/PET Scans, MRIs)
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible Cost share is based on place of service.
Preventive Care/Screening/Immunization
Covered
No Charge 60.00%
Routine Foot Care
Acupuncture
Weight Loss Programs
Routine Eye Exam for Children
Covered
No Charge No Charge 1 Exam(s) per Year Up to $38.50 OON
Eye Glasses for Children
Covered
No Charge No Charge 1 Item(s) per Year OON: Up to $50 for frames, $37.50 for lenses and $91 for contacts in lieu of eyeglasses. See EOC for lens limits.
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible25 Visit(s) per Benefit Period Maximum of 25 Outpatient visits for Physical Therapy, Occupational Therapy and Speech Therapy (combined).
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible25 Visit(s) per Benefit Period Maximum of 25 Outpatient visits for Physical Therapy, Occupational Therapy and Speech Therapy (combined).
Well Baby Visits and Care
Covered
No Charge 60.00%
Laboratory Outpatient and Professional Services
Covered
$30.00 60.00% Coinsurance after deductible Cost share is based on place of service.
X-rays and Diagnostic Imaging
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible Cost share is based on place of service.
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Covered
50.00% 50.00% $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults
Orthodontia – Adult
Major Dental Care – Adult
Covered
50.00% 50.00% $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults
Abortion for Which Public Funding is Prohibited
Transplant
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Accidental Dental
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Dialysis
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Allergy Testing
Covered
$60.00 60.00% Coinsurance after deductible Issuer clarifies this is a covered benefit but stipulated under the Medical Policy and not written in the member materials.
Chemotherapy
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Radiation
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Diabetes Education
Covered
$60.00 60.00% Coinsurance after deductible
Prosthetic Devices
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Infusion Therapy
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible25 Visit(s) per Benefit Period Covered under Outpatient Therapy Services.
Treatment for Temporomandibular Joint Disorders
Nutritional Counseling
Covered
$60.00 60.00% Coinsurance after deductible Diabetes self-management training and training related to medical nutrition therapy.
Reconstructive Surgery
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible Breast reconstruction or implantation or removal of breast prostheses is a Covered Service only when performed solely and directly as a result of mastectomy which is Medically Necessary.
Gender Affirming Care
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Other Services
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Substance Use Disorder Outpatient Other Services
Covered
40.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Mental/Behavioral Health Emergency Room
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Substance Use Disorder Emergency Room
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Mental/Behavioral Health ER Physician Fee
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Substance Use Disorder ER Physician Fee
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Mental/Behavioral Health Emergency Transportation/Ambulance
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Substance Use Disorder Emergency Transportation/Ambulance
Covered
40.00% Coinsurance after deductible 40.00% Coinsurance after deductible
Mental/Behavioral Health Urgent Care
Covered
$30.00 60.00%
Substance Use Disorder Urgent Care
Covered
$30.00 60.00%
Eyeglasses for Adults
Covered
No Charge No Charge 1 Item(s) per Year Covered up to $130

Free Preventive Services

There is no copayment or coinsurance for any of the following Complete Silver + Vision + Adult Dental preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Complete Silver + Vision + Adult Dental including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Complete Silver + Vision + Adult Dental?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Table of Contents