AultCare Standard Bronze Select No Pediatric Dental
28162OH0060080
Expanded Bronze
PPO
AultCare Standard Bronze Select No Pediatric Dental is an Expanded Bronze PPO plan by AultCare Insurance Company.
Locations
AultCare Standard Bronze Select No Pediatric Dental is offered in the following counties.
Plan Overview
This is a plan overview for 2025 version of AultCare Standard Bronze Select No Pediatric Dental 28162OH0060080.
| Insurer: | AultCare Insurance Company |
| Network Type: | PPO |
| Metal Type: | Expanded Bronze |
| HSA Eligible?: | No |
| Plan ID: | 28162OH0060080 |
Cost-Sharing Overview
AultCare Standard Bronze Select No Pediatric Dental offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for AultCare Standard Bronze Select No Pediatric Dental includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $9200 per person | $18400 per group |
| Deductible: | $7500 per person | $15000 per group |
| Coinsurance: | 50.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for AultCare Standard Bronze Select No Pediatric Dental will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | $27600 per person | $55200 per group |
| Out-of-Network Deductible: | $22500 per person | $45000 per group |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $7,500 |
| Copayment: | $10 |
| Coinsurance: | $300 |
| Limit: | $60 |
| Deductible: | $4,300 |
| Copayment: | $500 |
| Coinsurance: | $0 |
| Limit: | $20 |
| Deductible: | $2,600 |
| Copayment: | $200 |
| Coinsurance: | $0 |
| Limit: | $0 |
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 AultCare Standard Bronze Select No Pediatric 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
AultCare Standard Bronze Select No Pediatric Dental offers the following features and referral requirements.
| Wellness Program: | No |
| Disease Program: | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
| Notice Pregnancy: | No |
| 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 AultCare Standard Bronze Select No Pediatric Dental covers when you are out of the service area or out of the country.
| Out of Country Coverage: | Yes |
| Out of Country Coverage Description: | Generally, we may pay for limited Emergency Services that are necessary when You are traveling out of the USA, unless you are expressly traveling on business on behalf of Your Employer. We will consider each Claim carefully. We will not pay for Services when You go to another Country to obtain medical care. We do not pay for air transport or medical evacuation. We recommend that You obtain separate medical travel and evacuation insurance if You Plan to travel out of the USA. |
| Out of Service Area Coverage: | Yes |
| Out of Service Area Coverage Description: | Out of Service Area coverage from a network provider would be provided according to the plan benefits. Out of Service Area coverage from a Non-Network provider would be covered at the Non-Network plan benefits and the member would be responsible for any amounts exceeding plan limitations. |
| National Network: | No |
Additional Benefits and Cost-Sharing
AultCare Standard Bronze Select No Pediatric 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 | $50.00 Not Applicable | Not Applicable 60.00% Coinsurance after deductible | Primary Care Visit benefits and member cost share apply to services in a telehealth setting. Primary Care Visit benefits and member cost share apply to Mental Health and Substance Abuse services in an office or telehealth setting. |
| Specialist Visit Covered | $100.00 Not Applicable | Not Applicable 60.00% Coinsurance after deductible | Specialist Visit benefits and member cost share apply to services in a telehealth setting |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $50.00 Not Applicable | Not Applicable 60.00% Coinsurance after deductible | Other Practitioner Visit benefits and member cost share apply to services in a telehealth setting |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | See specific exceptions to these exclusions and/or additional exclusions that are detailed in plan document; benefits for facility charges for Outpatient Services are payable for the removal of teeth or for other dental processes only if the patient’s medical condition or the dental procedure requires a Hospital setting to ensure the safety of the patient |
| Outpatient Surgery Physician/Surgical Services Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | See specific exceptions to these exclusions and/or additional exclusions that are detailed in plan document. |
| Hospice Services Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | To be eligible for Hospice benefits, the patient must have a limited life expectancy, as confirmed by the attending Physician. |
| Routine Dental Services (Adult) Not Covered | |||
| Infertility Treatment Not Covered | Infertility and voluntary family planning services are required benefits under state law for HMO plans only per ORC section 1751.01 (A)(1)(h), and must be provided in accordance with Ohio Department of Insurance Bulletin No. 2009-07. | ||
| Long-Term/Custodial Nursing Home Care Not Covered | |||
| Private-Duty Nursing Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | 90.0 Visit(s) per Year Private Duty Nursing Services are Covered Services only when provided through the Home Care Services benefit; Quantitative Limit has been determined as 90 – 110 visits per year and represents the number of visits to meet the established actuarial equivalent of benchmark plan annual dollar limits. Annual and lifetime dollar limits will no longer apply. |
| Routine Eye Exam (Adult) Not Covered | |||
| Urgent Care Centers or Facilities Covered | $75.00 Not Applicable | $75.00 Not Applicable | |
| Home Health Care Services Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | 100.0 Visit(s) per Year When therapy services are provided in the home (including physical, speech, and occupational therapy) as part of home health care services, they are not subject to separate visit limits for therapy services. The 100 visit/year limit is also not applicable to home infusion therapy or private duty nursing rendered in the home setting. |
| Emergency Room Services Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Emergency Transportation/Ambulance Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | Ambulance Services are transportation by a vehicle (including ground, water, fixed wing and rotary wing air transportation) designed, equipped and used only to transport the sick and injured and staffed by Emergency Medical Technicians (EMT), paramedics, or other certified medical professionals: from home, scene of accident or medical emergency to a hospital; between hospitals; between a hospital and skilled nursing facility; or from a hospital or skilled nursing facility to home; ambulance trips must be made to the closest facility that can give covered services appropriate for the member’s condition. |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | There are specific exceptions to certain exclusions and/or additional exclusions that are detailed in plan document; inpatient hospital services include charges from a hospital, skilled nursing facility or other provider for room, board, general nursing services; and ancillary (related) services. |
| Inpatient Physician and Surgical Services Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | There are specific exceptions to certain exclusions and/or additional exclusions that are detailed in plan document; inpatient medical care visits limited to one visit per day by any one physician. |
| Bariatric Surgery Not Covered | |||
| Cosmetic Surgery Not Covered | |||
| Skilled Nursing Facility Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | 90.0 Days per Year Benefits include Items and services provided as an inpatient in a skilled nursing bed of skilled nursing facility or hospital, including room and board in semi-private accommodations; rehabilitative services; and drugs, biologicals, and supplies furnished for use in the skilled nursing facility and other medically necessary services and supplies. |
| Prenatal and Postnatal Care Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | Cost sharing does not apply to certain preventive services. Depending on the type of service, a copayment, deductible, or coinsurance may apply. Includes post-delivery follow-up care performed, by a physician or nurse, within 72 hours of discharge, through home health care visits or, at patient’s discretion, in a medical setting. This coverage includes, but is not limited to parent education; assistance and training in breast or bottle feeding; and routine maternal or neonatal tests and screening (including collection of sample for hereditary and metabolic newborn screening). |
| Delivery and All Inpatient Services for Maternity Care Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | Coverage for the Inpatient postpartum stay for mother and newborn child in a hospital will be, at a minimum, 48 hours for a vaginal delivery and 96 hours for a cesarean section. Coverage will be for the length of stay recommended by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists in their Guidelines for Prenatal Care. |
| Mental/Behavioral Health Outpatient Services Covered | $50.00 Not Applicable | Not Applicable 60.00% Coinsurance after deductible | Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. The cost sharing that displays applies to outpatient office visits only. All other outpatient services [e.g., outpatient facility services, outpatient facility therapy] may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information. |
| Mental/Behavioral Health Inpatient Services Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
| Substance Abuse Disorder Outpatient Services Covered | $50.00 Not Applicable | Not Applicable 60.00% Coinsurance after deductible | Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. The cost sharing that displays applies to outpatient office visits only. All other outpatient services [e.g., outpatient facility services, outpatient facility therapy] may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information. |
| Substance Abuse Disorder Inpatient Services Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. |
| Generic Drugs Covered | $25.00 Not Applicable | $25.00 Not Applicable | Preventive Maintenance Tier 1 drugs are covered with no cost share, including over-the-counter drugs, stop smoking aids, and nutritional or dietary supplements required by Preventive/Screening/Immunization benefits. Generic Tier 2 drugs are covered with $25 Copayment. Generic Tier 3 drugs are covered with $50 Copayment after the Deductible is met. Generic Tier 4 drugs are covered with $100 Copayment after the Deductible is met. |
| Preferred Brand Drugs Covered | $50.00 Copay after deductible Not Applicable | $50.00 Copay after deductible Not Applicable | Preferred Brand Tier 3 drugs are covered with $50 Copayment after the Deductible is met. |
| Non-Preferred Brand Drugs Covered | $100.00 Copay after deductible Not Applicable | $100.00 Copay after deductible Not Applicable | Non-Preferred Brand Tier 4 drugs are covered with $100 Copayment after the Deductible is met. |
| Specialty Drugs Covered | $500.00 Copay after deductible Not Applicable | $500.00 Copay after deductible Not Applicable | Specialty drugs exclude purchases through retail pharmacies. Specialty drugs can only be purchased with a one-month supply through mail order only using a contracted AultCare Specialty network pharmacy. Specialty Tier 5 drugs are covered with $500 Copayment after the Deductible is met. Specialty drugs can only be purchased with a one-month supply through mail order only using a contracted AultCare Specialty network pharmacy. |
| Outpatient Rehabilitation Services Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | 116.0 Visit(s) per Year Therapy Services rendered in the home as part of Home Care Services will be subject to the Home Care Services visit limits; outpatient rehabilitation services visit limits will not apply. If different types of Therapy Services are performed during one Physician Home Visit, Office Service, or Outpatient Service, then each different type of Therapy Service performed will be considered a separate Therapy Visit. Each Therapy Visit will count against the applicable maximum visits per Benefit Period listed below: Physical and Occupational Therapy limited to 40 visits combined. Speech Therapy limited to 20 visits. Cardiac Rehabilitation limited to 36 visits. Pulmonary Rehabilitation limited to 20 visits, except if rendered as part of Physical Therapy, the Physical Therapy visit limit will apply. Benefit also includes Physical Medicine and Rehabilitation Day Rehabilitation Therapy services on an Outpatient basis. Limited to a combined 60 days per Year maximum for both Inpatient and outpatient day rehabilitation therapy services. |
| Habilitation Services Covered | $50.00 Not Applicable | Not Applicable 60.00% Coinsurance after deductible | Limits may apply to some services; includes benefits for health care services and devices that help a person keep, learn or improve skills and functioning for daily living, including treatment of Autism Spectrum Disorders to children (0 – 21), which at a minimum shall include: (1) Out-Patient Physical Rehabilitation Services including (a) Speech and Language therapy and/or Occupational therapy, 20 visits per year of each service; and (b) Clinical Therapeutic Intervention, which include but are not limited to Applied Behavioral Analysis, 20 hours per week; and (2) Mental/Behavioral Health Outpatient Services to provide consultation, assessment, development and oversight of treatment plans. |
| Chiropractic Care Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | 12.0 Treatment(s) per Year Benefit limit applies for Osteopathic/Chiropractic Manipulation Therapy. |
| Durable Medical Equipment Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | Covered services include durable medical equipment, medical devices and supplies, prosthetics and appliances, including cochlear implants and eyeglasses/contact lenses (for cataract surgery or injury), and medical/surgical supplies and equipment that serve only a medical purpose for the management of disease. Benefit limits: Wigs are limited to the first one following cancer treatment not to exceed one per Benefit Period; limit of four (4) surgical bras following mastectomy per benefit period; (as required by the Women’s Health and Cancer Rights Act); Left Ventricular Artificial Devices (LVAD) covered only as bridge to heart transplant. |
| Hearing Aids Not Covered | |||
| Imaging (CT/PET Scans, MRIs) Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | |
| Preventive Care/Screening/Immunization Covered | Not Applicable 0.00% | Not Applicable 60.00% Coinsurance after deductible | Services with an ‘A’ or ‘B’ rating from the United States Preventive Services Task Force (USPSTF); Immunizations for children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; Preventive care and screenings for infants, children and adolescents as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Additional preventive care and screening for women provided for in the guidelines supported by the Health Resources and Services Administration including: women’s contraceptives, sterilization procedures, and counseling; breastfeeding support, supplies, and counseling (benefits for breast pumps are limited to one pump per benefit period); and gestational diabetes screening; routine screening mammograms; routine cytologic screening; child health supervision services from birth to age 9. |
| Routine Foot Care Not Covered | |||
| Acupuncture Not Covered | |||
| Weight Loss Programs Not Covered | |||
| Routine Eye Exam for Children Covered | Not Applicable 0.00% | Not Applicable 60.00% Coinsurance after deductible | 1.0 Exam(s) per Year Coverage includes benefits specified in the FEDVIP FEP Blue Vision – High Option plan, including low vision benefits. |
| Eye Glasses for Children Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | 1.0 Item(s) per Year Coverage includes benefits specified in the FEDVIP FEP Blue Vision – High Option plan, including low vision benefits. |
| Dental Check-Up for Children Not Covered | |||
| Rehabilitative Speech Therapy Covered | $50.00 Not Applicable | Not Applicable 60.00% Coinsurance after deductible | 20.0 Visit(s) per Year |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | $50.00 Not Applicable | Not Applicable 60.00% Coinsurance after deductible | 40.0 Visit(s) per Year Physical and Occupational Therapy limited to 40 visits combined per benefit period. |
| Well Baby Visits and Care Covered | Not Applicable 0.00% | Not Applicable 60.00% Coinsurance after deductible | |
| Laboratory Outpatient and Professional Services Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | |
| X-rays and Diagnostic Imaging Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | |
| Basic Dental Care – Child Not Covered | |||
| Orthodontia – Child Not Covered | |||
| Major Dental Care – Child Not Covered | |||
| Basic Dental Care – Adult Not Covered | |||
| Orthodontia – Adult Not Covered | |||
| Major Dental Care – Adult Not Covered | |||
| Abortion for Which Public Funding is Prohibited Not Covered | |||
| Transplant Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | Includes coverage for unrelated donor search services ($30,000 per transplant/network & Non network combined) and travel/lodging as approved by the plan ($10,000 per transplant/network & Non network combined). Transplant benefits apply to any medically necessary human organ and stem cell/bone marrow transplants and transfusions including necessary acquisition procedures, harvest and storage, necessary preparatory myeloablative therapy, and initial evaluation/testing to determine eligibility as a transplant candidate. |
| Accidental Dental Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | 3000.0 Dollars per Episode Quantitative Limit represents established actuarial equivalent of benchmark plan annual dollar limits. Annual and lifetime dollar limits will no longer apply. Coverage for dental services resulting from an accidental injury when treatment is performed within 12 months after the injury. The benefit limit will not apply to outpatient facility charges, anesthesia billed by a provider other than the physician performing the service, or to covered services required by law; coverage includes oral examinations, x-rays, tests and laboratory examinations, restorations, prosthetic services, oral surgery, mandibular/maxillary reconstruction, anesthesia and include facility charges for outpatient services for the removal of teeth or for other dental processes if the patient’s medical condition or the dental procedure requires a hospital setting to ensure the safety of the patient. |
| Dialysis Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | Benefits include supportive use of an artificial kidney machine. |
| Allergy Testing Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | |
| Chemotherapy Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | |
| Radiation Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | |
| Diabetes Education Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | Diabetes Self-Management Training for an individual with insulin dependent diabetes, non-insulin dependent diabetes, or elevated blood glucose levels induced by pregnancy or another medical condition. |
| Prosthetic Devices Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | Benefits for artificial substitutes for body parts and tissues and materials inserted into tissue for functional or therapeutic purposes. Covered Services include purchase, fitting, needed adjustment, repairs, and replacements of prosthetic devices and supplies that 1) Replace all or part of a missing body part and its adjoining tissues; or 2) Replace all or part of the function of a permanently useless or malfunctioning body part. |
| Infusion Therapy Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | Home IV therapy includes but is not limited to: injections (intra-muscular, subcutaneous, continuous subcutaneous), Total Parenteral Nutrition (TPN), Enteral nutrition therapy, antibiotic therapy, pain management and chemotherapy. |
| Treatment for Temporomandibular Joint Disorders Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | Benefits provided for temporomandibular (joint connecting the lower jaw to the temporal bone at the side of the head) and craniomandibular (head and neck muscle) disorders. |
| Nutritional Counseling Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | Covered benefit under home health services and covered as USPSTF A or B recommendation under preventive health services (includes diet counseling for adults at higher risk for chronic disease, obesity screening and counseling for all adults, and healthy diet counseling for adults with cardiovascular risk factors). |
| Reconstructive Surgery Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible | Benefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance. Benefits include surgery performed to restore symmetry after a mastectomy. |
| Gender Affirming Care Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 60.00% Coinsurance after deductible |
Free Preventive Services
There is no copayment or coinsurance for any of the following AultCare Standard Bronze Select No Pediatric 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.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for AultCare Standard Bronze Select No Pediatric 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 AultCare Standard Bronze Select No Pediatric 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