Standard Gold (QualChoiceLife)

37903AR0070034
Gold
PPO

Standard Gold (QualChoiceLife) is a Gold PPO plan by Ambetter from Arkansas Health & Wellness.

IMPORTANT: You are viewing the 2024 version of Standard Gold (QualChoiceLife) 37903AR0070034. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

Standard Gold (QualChoiceLife) is offered in the following counties.

No data was found

Plan Overview

This is a plan overview for 2024 version of Standard Gold (QualChoiceLife) 37903AR0070034.
Insurer: Ambetter from Arkansas Health & Wellness
Network Type: PPO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 37903AR0070034

Cost-Sharing Overview

Standard Gold (QualChoiceLife) 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 Standard Gold (QualChoiceLife)?

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

Standard Gold (QualChoiceLife) 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 Standard Gold (QualChoiceLife) 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

Standard Gold (QualChoiceLife) 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 Not ApplicableNot Applicable 50.00%
Specialist Visit
Covered
$60.00 Not ApplicableNot Applicable 50.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$30.00 Not ApplicableNot Applicable 50.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Hospice Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Prior authorization may be required. Coverage includes testing to diagnose infertility, infertility counseling and planning services; also, in vitro fertilization procedures are covered.
Long-Term/Custodial Nursing Home Care
Not Covered
Long Term Acute Care is a covered benefit. Long Term Nursing Care/Custodial Care is not a covered benefit.
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$45.00 Not ApplicableNot Applicable 50.00%
Home Health Care Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible50.0 Visit(s) per Year Prior authorization may be required – please contact the number listed on your ID card.
Emergency Room Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 25.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 25.00% Coinsurance after deductible Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Inpatient Physician and Surgical Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible60.0 Days per Year Prior authorization may be required – please contact the number listed on you ID card.
Prenatal and Postnatal Care
Covered
$30.00 Not ApplicableNot Applicable 50.00%
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Mental/Behavioral Health Outpatient Services
Covered
$30.00 Not ApplicableNot Applicable 50.00% Cost sharing shown applies to outpatient office visits only.?See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization. Cost share will be waived for Behavioral Health screening services.
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Substance Abuse Disorder Outpatient Services
Covered
$30.00 Not ApplicableNot Applicable 50.00% Cost sharing shown applies to outpatient office visits only.?See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization. Cost share will be waived for Behavioral Health screening services.
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Generic Drugs
Covered
$15.00 Not ApplicableNot Applicable 100.00% Cost sharing shown applies to Tier 2-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 3-Generic Drugs, which may apply a higher cost share. Up to a 30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. Refer to the prescription drug list for more information.
Preferred Brand Drugs
Covered
$30.00 Not ApplicableNot Applicable 100.00%
Non-Preferred Brand Drugs
Covered
$60.00 Not ApplicableNot Applicable 100.00%
Specialty Drugs
Covered
$250.00 Not ApplicableNot Applicable 100.00%
Outpatient Rehabilitation Services
Covered
$30.00 Not ApplicableNot Applicable 50.00% Coinsurance after deductible30.0 Visit(s) per Year Prior authorization may be required – please contact the number listed on your ID card. Limited to a combined 30 visit limit per year for outpatient physical therapy, speech therapy, occupational therapy, and chiropractic care. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.
Habilitation Services
Covered
$30.00 Not ApplicableNot Applicable 50.00% Coinsurance after deductible30.0 Visit(s) per Year Prior authorization may be required – please contact the number listed on your ID card. Limited to a combined 30 visit limit per year for outpatient habilitation services; limited to 180 visits per year for developmental services. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.
Chiropractic Care
Covered
$60.00 Not ApplicableNot Applicable 50.00%30.0 Visit(s) per Year Limited to a combined 30 visit limit per year for outpatient physical therapy, speech therapy, occupational therapy, and chiropractic care. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.
Durable Medical Equipment
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Hearing Aids
Covered
Not Applicable 25.00%Not Applicable 50.00%2.0 Item(s) per 3 Years Prior authorization may be required – please contact the number listed on your ID card.
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Preventive Care/Screening/Immunization
Covered
Not Applicable 0.00%Not Applicable 50.00% Covered in accordance with ACA guidelines.
Routine Foot Care
Covered
$60.00 Not ApplicableNot Applicable 50.00%
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge Not ApplicableNo Charge Not Applicable1.0 Exam(s) per Year Up to $38.50 OON
Eye Glasses for Children
Covered
No Charge Not ApplicableNo Charge Not Applicable1.0 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
$30.00 Not ApplicableNot Applicable 50.00% Coinsurance after deductible30.0 Visit(s) per Year Prior authorization may be required – please contact the number listed on your ID card. Limited to a combined 30 visit limit per year for outpatient physical therapy, speech therapy, occupational therapy, and chiropractic care. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$30.00 Not ApplicableNot Applicable 50.00% Coinsurance after deductible30.0 Visit(s) per Year 60 inpatient days/year. Prior authorization may be required – please contact the number listed on your ID card. Limited to a combined 30 visit limit per year for outpatient physical therapy, speech therapy, occupational therapy, and chiropractic care. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.
Well Baby Visits and Care
Covered
No Charge Not ApplicableNot Applicable 50.00%
Laboratory Outpatient and Professional Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Prior authorization may be required – please contact the number listed on your ID card.
X-rays and Diagnostic Imaging
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
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 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Accidental Dental
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Dialysis
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Allergy Testing
Covered
$60.00 Not ApplicableNot Applicable 50.00% Prior authorization may be required – please contact the number listed on your ID card.
Chemotherapy
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Radiation
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Diabetes Education
Covered
$60.00 Not ApplicableNot Applicable 50.00% Prior authorization may be required – please contact the number listed on your ID card.
Prosthetic Devices
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Infusion Therapy
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card.
Nutritional Counseling
Covered
$60.00 Not ApplicableNot Applicable 50.00%
Reconstructive Surgery
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible 1. Treatment provided for the correction of defects incurred in an Accidental Injury sustained by the Member; 2. Surgery performed on a child for the correction of a cleft palate or cleft lip, removal of a port-wine stain or hemangioma (only on the face), or correction of a congenital abnormality… 3. Treatment provided when it is incidental to disease or for reconstructive surgery following neoplastic (cancer) surgery; 4. In connection with a mastectomy resulting from cancer surgery, services for (a) reconstruction of the breast on which the cancer-related surgery was performed; (b) surgery to reconstruct the other breast to produce a symmetrical appearance; and (c) prostheses and services to correct physical complications for all stages of the mastectomy, including lymphedemas; 5. Reduction mammoplasty, if such reduction mammoplasty meets Coverage Criteria. Prior Authorization may be required – please contact the number listed on your ID card.
Gender Affirming Care
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Other Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card. Note: Cost share will be waived for Behavioral Health screening services.
Substance Use Disorder Outpatient Other Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible Prior authorization may be required – please contact the number listed on your ID card. Note: Cost share will be waived for Behavioral Health screening services.
Mental/Behavioral Health Emergency Room
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 25.00% Coinsurance after deductible
Substance Use Disorder Emergency Room
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 25.00% Coinsurance after deductible
Mental/Behavioral Health ER Physician Fee
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 25.00% Coinsurance after deductible
Substance Use Disorder ER Physician Fee
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 25.00% Coinsurance after deductible
Mental/Behavioral Health Emergency Transportation/Ambulance
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 25.00% Coinsurance after deductible Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization.
Substance Use Disorder Emergency Transportation/Ambulance
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 25.00% Coinsurance after deductible Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization.
Mental/Behavioral Health Urgent Care
Covered
$45.00 Not ApplicableNot Applicable 50.00%
Substance Use Disorder Urgent Care
Covered
$45.00 Not ApplicableNot Applicable 50.00%
Applied Behavior Analysis Based Therapies
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Cardiac Rehabilitation
Covered
$30.00 Not ApplicableNot Applicable 50.00% Coinsurance after deductible36.0 Visit(s) per Year
Cochlear Implants
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Craniofacial Surgery
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Dental Anesthesia
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Diabetes Care Management
Covered
$60.00 Not ApplicableNot Applicable 50.00%
Gastric Electrical Stimulation
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Inherited Metabolic Disorder – PKU
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 50.00%
Off Label Prescription Drugs
Covered
$250.00 Not ApplicableNot Applicable 100.00%
Preventative Drugs
Covered
No Charge Not ApplicableNot Applicable 100.00%
Well Child Care
Covered
No Charge Not ApplicableNot Applicable 50.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following Standard Gold (QualChoiceLife) 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 Standard Gold (QualChoiceLife) 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 Standard Gold (QualChoiceLife)?

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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