CMS Standard Expanded Bronze

62505OK0120019
Expanded Bronze
PPO

CMS Standard Expanded Bronze is an Expanded Bronze PPO plan by Ambetter of Oklahoma.

IMPORTANT: You are viewing the 2023 version of CMS Standard Expanded Bronze 62505OK0120019. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

CMS Standard Expanded Bronze is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of CMS Standard Expanded Bronze 62505OK0120019.
Insurer: Ambetter of Oklahoma
Network Type: PPO
Metal Type: Expanded Bronze
HSA Eligible?: No
Plan ID: 62505OK0120019

Cost-Sharing Overview

CMS Standard Expanded Bronze 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 CMS Standard Expanded Bronze?

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

CMS Standard Expanded Bronze 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 CMS Standard Expanded Bronze 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

CMS Standard Expanded Bronze 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 60.00% Coinsurance after deductible Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge.
Specialist Visit
Covered
$100.00 60.00% Coinsurance after deductible
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$50.00 60.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
50.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
Covered
50.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Hospice Services
Covered
50.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Routine Dental Services (Adult)
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Covered
50.00% Coinsurance after deductible 60.00% Coinsurance after deductible85 Visit(s) per Benefit Period Pre-authorization required.
Routine Eye Exam (Adult)
Urgent Care Centers or Facilities
Covered
$75.00 60.00%
Home Health Care Services
Covered
50.00% Coinsurance after deductible 60.00% Coinsurance after deductible30 Visit(s) per Benefit Period
Emergency Room Services
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
50.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
Covered
50.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Bariatric Surgery
Cosmetic Surgery
Skilled Nursing Facility
Covered
50.00% Coinsurance after deductible 60.00% Coinsurance after deductible30 Days per Benefit Period
Prenatal and Postnatal Care
Covered
$50.00 60.00% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
Covered
50.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services
Covered
$50.00 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
50.00% 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
$50.00 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
50.00% 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
$25.00 100.00% 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
$50.00 Copay after deductible 100.00%
Non-Preferred Brand Drugs
Covered
$100.00 Copay after deductible 100.00%
Specialty Drugs
Covered
$500.00 Copay after deductible 100.00%
Outpatient Rehabilitation Services
Covered
$50.00 60.00% Coinsurance after deductible30 Days per Benefit Period
Habilitation Services
Covered
$50.00 60.00% Coinsurance after deductible25 Visit(s) per Benefit Period
Chiropractic Care
Covered
$100.00 60.00% Coinsurance after deductible
Durable Medical Equipment
Covered
50.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Hearing Aids
Covered
50.00% Coinsurance after deductible 60.00% Coinsurance after deductible One hearing aid per ear every 48 months.
Imaging (CT/PET Scans, MRIs)
Covered
50.00% Coinsurance after deductible 60.00% Coinsurance after deductible Cost share is based on place of service.
Preventive Care/Screening/Immunization
Covered
0.00% 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
$50.00 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
$50.00 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
50.00% Coinsurance after deductible 60.00% Coinsurance after deductible Cost share is based on place of service.
X-rays and Diagnostic Imaging
Covered
50.00% 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
Orthodontia – Adult
Major Dental Care – Adult
Abortion for Which Public Funding is Prohibited
Transplant
Covered
50.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Accidental Dental
Covered
50.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Dialysis
Covered
50.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Allergy Testing
Covered
$100.00 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
50.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Radiation
Covered
50.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Diabetes Education
Covered
$100.00 60.00% Coinsurance after deductible
Prosthetic Devices
Covered
50.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Infusion Therapy
Covered
50.00% 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
$100.00 60.00% Coinsurance after deductible Diabetes self-management training and training related to medical nutrition therapy.
Reconstructive Surgery
Covered
50.00% 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
50.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Other Services
Covered
50.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Substance Use Disorder Outpatient Other Services
Covered
50.00% Coinsurance after deductible 60.00% Coinsurance after deductible
Mental/Behavioral Health Emergency Room
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Substance Use Disorder Emergency Room
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Mental/Behavioral Health ER Physician Fee
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Substance Use Disorder ER Physician Fee
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Mental/Behavioral Health Emergency Transportation/Ambulance
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Substance Use Disorder Emergency Transportation/Ambulance
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Mental/Behavioral Health Urgent Care
Covered
$75.00 60.00%
Substance Use Disorder Urgent Care
Covered
$75.00 60.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following CMS Standard Expanded Bronze 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 CMS Standard Expanded Bronze 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 CMS Standard Expanded Bronze?

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

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