Standard Gold + Vision + Adult Dental
49004FL0020024
Gold
HMO
Standard Gold + Vision + Adult Dental is a Gold HMO plan by Ambetter Health.
Locations
Standard Gold + Vision + Adult Dental is offered in the following counties.
Plan Overview
This is a plan overview for 2025 version of Standard Gold + Vision + Adult Dental 49004FL0020024.
| Insurer: | Ambetter Health |
| Network Type: | HMO |
| Metal Type: | Gold |
| HSA Eligible?: | No |
| Plan ID: | 49004FL0020024 |
Cost-Sharing Overview
Standard Gold + Vision + Adult Dental offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Standard Gold + Vision + Adult Dental includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $7800 per person | $15600 per group |
| Deductible: | $1500 per person | $3000 per group |
| Coinsurance: | 25.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Standard Gold + Vision + Adult Dental will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | per person not applicable | per group not applicable |
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: | $1,500 |
| Copayment: | $40 |
| Coinsurance: | $2,100 |
| Limit: | $60 |
| Deductible: | $900 |
| Copayment: | $900 |
| Coinsurance: | $0 |
| Limit: | $20 |
| Deductible: | $1,500 |
| Copayment: | $300 |
| Coinsurance: | $100 |
| 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 Standard Gold + 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
Standard Gold + 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 Standard Gold + 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
Standard Gold + 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 Not Applicable | Not Applicable 100.00% | |
| Specialist Visit Covered | $60.00 Not Applicable | Not Applicable 100.00% | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $30.00 Not Applicable | Not Applicable 100.00% | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Outpatient Surgery Physician/Surgical Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Hospice Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | Respite Care is covered as part of hospice services only. |
| Routine Dental Services (Adult) Covered | No Charge Not Applicable | Not Applicable 100.00% | 1000.0 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults |
| Infertility Treatment Not Covered | Limited to services for diagnostic tests to find the cause of infertility. Services to treat the underlying medical conditions that cause infertility are covered (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency). | ||
| 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) Covered | No Charge Not Applicable | Not Applicable 100.00% | 1.0 Exam(s) per Year Benefit also includes 1 pair of eye glasses or contacts per year, covered up to $130 In-Network for frames or $130 In-Network for contacts in lieu of eye glasses. |
| Urgent Care Centers or Facilities Covered | $45.00 Not Applicable | Not Applicable 100.00% | |
| Home Health Care Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | 20.0 Visit(s) per Year |
| Emergency Room Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 25.00% Coinsurance after deductible | |
| Emergency Transportation/Ambulance Covered | Not Applicable 25.00% Coinsurance after deductible | Not 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 deductible | Not Applicable 100.00% | |
| Inpatient Physician and Surgical Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Bariatric Surgery Not Covered | |||
| Cosmetic Surgery Not Covered | |||
| Skilled Nursing Facility Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | 60.0 Days per Year |
| Prenatal and Postnatal Care Covered | $30.00 Not Applicable | Not Applicable 100.00% | |
| Delivery and All Inpatient Services for Maternity Care Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Mental/Behavioral Health Outpatient Services Covered | $30.00 Not Applicable | Not Applicable 100.00% | 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. |
| Mental/Behavioral Health Inpatient Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | Prior authorization may be required – please contact the number listed on your ID card. |
| Substance Abuse Disorder Outpatient Services Covered | $30.00 Not Applicable | Not Applicable 100.00% | 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. |
| Substance Abuse Disorder Inpatient Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | Prior authorization may be required – please contact the number listed on your ID card. |
| Generic Drugs Covered | $15.00 Not Applicable | Not Applicable 100.00% | Cost sharing shown applies to Tier 1a-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 1b-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 Applicable | Not Applicable 100.00% | |
| Non-Preferred Brand Drugs Covered | $60.00 Not Applicable | Not Applicable 100.00% | |
| Specialty Drugs Covered | $250.00 Not Applicable | Not Applicable 100.00% | |
| Outpatient Rehabilitation Services Covered | $30.00 Not Applicable | Not Applicable 100.00% | 35.0 Visit(s) per Year Outpatient rehabilitation therapy is limited to a combined 35 visits per year, including chiropractic care. |
| Habilitation Services Covered | $30.00 Not Applicable | Not Applicable 100.00% | 35.0 Visit(s) per Year Outpatient rehabilitation therapy is limited to a combined 35 visits per year, including chiropractic care. |
| Chiropractic Care Covered | $60.00 Not Applicable | Not Applicable 100.00% | 35.0 Visit(s) per Year Limited to a combined 35 visits per year, including outpatient therapy. |
| Durable Medical Equipment Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Hearing Aids Not Covered | Cochlear Implants and Bone Anchored Hearing Aids are not a covered benefit. | ||
| Imaging (CT/PET Scans, MRIs) Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Preventive Care/Screening/Immunization Covered | Not Applicable 0.00% | Not Applicable 100.00% | Covered in accordance with ACA guidelines. |
| Routine Foot Care Covered | $60.00 Not Applicable | Not Applicable 100.00% | |
| Acupuncture Not Covered | |||
| Weight Loss Programs Not Covered | |||
| Routine Eye Exam for Children Covered | No Charge Not Applicable | Not Applicable 100.00% | 1.0 Exam(s) per Year |
| Eye Glasses for Children Covered | No Charge Not Applicable | Not Applicable 100.00% | 1.0 Item(s) per Year |
| Dental Check-Up for Children Not Covered | |||
| Rehabilitative Speech Therapy Covered | $30.00 Not Applicable | Not Applicable 100.00% | 35.0 Visit(s) per Year Outpatient rehabilitation therapy is limited to a combined 35 visits per year, including chiropractic care. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | $30.00 Not Applicable | Not Applicable 100.00% | 35.0 Visit(s) per Year Outpatient rehabilitation therapy is limited to a combined 35 visits per year, including chiropractic care. |
| Well Baby Visits and Care Covered | No Charge Not Applicable | Not Applicable 100.00% | Covered in accordance with ACA guidelines. |
| Laboratory Outpatient and Professional Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | |
| X-rays and Diagnostic Imaging Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Basic Dental Care – Child Not Covered | |||
| Orthodontia – Child Not Covered | |||
| Major Dental Care – Child Not Covered | |||
| Basic Dental Care – Adult Covered | Not Applicable 50.00% | Not Applicable 100.00% | 1000.0 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults |
| Orthodontia – Adult Not Covered | |||
| Major Dental Care – Adult Covered | Not Applicable 50.00% | Not Applicable 100.00% | 1000.0 Dollars per Year $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults |
| Abortion for Which Public Funding is Prohibited Not Covered | |||
| Transplant Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant. |
| Accidental Dental Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Dialysis Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Allergy Testing Covered | $60.00 Not Applicable | Not Applicable 100.00% | |
| Chemotherapy Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Radiation Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Diabetes Education Covered | $60.00 Not Applicable | Not Applicable 100.00% | |
| Prosthetic Devices Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Infusion Therapy Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Treatment for Temporomandibular Joint Disorders Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Nutritional Counseling Covered | $60.00 Not Applicable | Not Applicable 100.00% | |
| Reconstructive Surgery Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | 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 deductible | Not Applicable 100.00% | |
| Mental/Behavioral Health Outpatient Other Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Substance Use Disorder Outpatient Other Services Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Mental/Behavioral Health Emergency Room Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 25.00% Coinsurance after deductible | |
| Substance Use Disorder Emergency Room Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 25.00% Coinsurance after deductible | |
| Mental/Behavioral Health ER Physician Fee Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 25.00% Coinsurance after deductible | |
| Substance Use Disorder ER Physician Fee Covered | Not Applicable 25.00% Coinsurance after deductible | Not Applicable 25.00% Coinsurance after deductible | |
| Mental/Behavioral Health Emergency Transportation/Ambulance Covered | Not Applicable 25.00% Coinsurance after deductible | Not 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 deductible | Not 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 | $30.00 Not Applicable | Not Applicable 100.00% | |
| Substance Use Disorder Urgent Care Covered | $30.00 Not Applicable | Not Applicable 100.00% |
Free Preventive Services
There is no copayment or coinsurance for any of the following Standard Gold + 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.
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 Standard Gold + 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 Standard Gold + 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