Ambetter Essential Care 5 (2021) Plan Details for 2021- HealthPocket

Costs for Medical Care
Primary Care Visit to Treat an Injury or Illness	$40 Copay
Specialist Visit	$90 Copay
Laboratory Outpatient and Professional Services	$45 Copay
X-rays and Diagnostic Imaging	50.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans	50.00% Coinsurance after deductible
Deductible - Family	$16200 per group
Out-of-Pocket Maximum - Family	$17000 per group

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness

$40 Copay

Specialist Visit

$90 Copay

Laboratory Outpatient and Professional Services

$45 Copay

X-rays and Diagnostic Imaging

50.00% Coinsurance after deductible

Diagnostic Imaging such as MRIs, CT, and PET scans

50.00% Coinsurance after deductible

Deductible - Family

$16200 per group

Out-of-Pocket Maximum - Family

$17000 per group

Prescription drug coverage
Generic Drugs	$30 Copay
Preferred Brand Drugs	50.00% Coinsurance after deductible
Non-Preferred Brand Drugs	50.00% Coinsurance after deductible
Specialty Drugs	50.00% Coinsurance after deductible

Prescription drug coverage

Generic Drugs

$30 Copay

Preferred Brand Drugs

50.00% Coinsurance after deductible

Non-Preferred Brand Drugs

50.00% Coinsurance after deductible

Specialty Drugs

50.00% Coinsurance after deductible

Access to doctors and hospitals
Provider directory URL	https://ambetter.azcompletehealth.com/find-a-provider.html
Does this plan have access to a national provider network?	No
Is a referral required to see a Specialist?	Not Covered
Does this plan cover services outside plan service area?	Not Covered
Does this plan cover services outside the country?	Not Covered

Access to doctors and hospitals

Provider directory URL

https://ambetter.azcompletehealth.com/find-a-provider.html

Does this plan have access to a national provider network?

Is a referral required to see a Specialist?

Not Covered

Does this plan cover services outside plan service area?

Not Covered

Does this plan cover services outside the country?

Not Covered

Hospital services
Emergency Room Services	50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services	50.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service	50.00% Coinsurance after deductible

Hospital services

Emergency Room Services

50.00% Coinsurance after deductible

Inpatient Hospital Services (e.g., Hospital Stay)

50.00% Coinsurance after deductible

Inpatient Physician and Surgical Services

50.00% Coinsurance after deductible

Emergency Transportation or Ambulance Service

50.00% Coinsurance after deductible

Maternity
Prenatal and Postnatal Care	$40 Copay
Delivery and all inpatient services for maternity care	50.00% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care

$40 Copay

Delivery and all inpatient services for maternity care

50.00% Coinsurance after deductible

Mental Health
Mental/Behavioral Health Outpatient Services	$40 Copay
Mental/Behavioral Health Inpatient Services	50.00% Coinsurance after deductible
Substance use disorder outpatient services	$40 Copay
Substance use disorder inpatient services	50.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services

$40 Copay

Mental/Behavioral Health Inpatient Services

50.00% Coinsurance after deductible

Substance use disorder outpatient services

$40 Copay

Substance use disorder inpatient services

50.00% Coinsurance after deductible

Medical Management Programs
Does this plan offer disease managment programs?	Asthma, Diabetes, Heart Disease, Pregnancy
Does this plan offer a wellness program?	Included

Medical Management Programs

Does this plan offer disease managment programs?

Asthma, Diabetes, Heart Disease, Pregnancy

Does this plan offer a wellness program?

Included

Vision Coverage
Routine Eye Exam for Children	Included
Eye Glasses for Children	Included
Routine Eye Exam for Adults	Not Covered

Vision Coverage

Routine Eye Exam for Children

Included

Eye Glasses for Children

Included

Routine Eye Exam for Adults

Not Covered

Child Dental Coverage
Child Dental Coverage - Routine Dental Care	Not Covered
Child Dental Coverage - Basic Dental Care	Not Covered
Child Dental Coverage - Orthodontia	Not Covered
Child Dental Coverage - Major Dental Care	Not Covered

Child Dental Coverage

Child Dental Coverage - Routine Dental Care

Not Covered

Child Dental Coverage - Basic Dental Care

Not Covered

Child Dental Coverage - Orthodontia

Not Covered

Child Dental Coverage - Major Dental Care

Not Covered

Adult Dental Coverage
Adult Dental Coverage - Routine Dental Care	Not Covered
Adult Dental Coverage - Basic Dental Care	Not Covered
Adult Dental Coverage - Orthodontia	Not Covered
Adult Dental Coverage - Major Dental Care	Not Covered

Adult Dental Coverage

Adult Dental Coverage - Routine Dental Care

Not Covered

Adult Dental Coverage - Basic Dental Care

Not Covered

Adult Dental Coverage - Orthodontia

Not Covered

Adult Dental Coverage - Major Dental Care

Not Covered

Exclusions and Limitations
More Included Benefits	Other Practitioner Office Visit (Nurse, Physician Assistant) Bariatric Surgery Private-Duty Nursing Imaging (CT/PET Scans, MRIs) Outpatient Surgery Physician/Surgical Services Urgent Care Centers or Facilities Inpatient Physician and Surgical Services Durable Medical Equipment Hospice Services Routine Foot Care Diabetes Care Management Inherited Metabolic Disorder - PKU Accidental Dental Allergy Testing Chemotherapy Diabetes Education Dialysis Infusion Therapy Laboratory Outpatient and Professional Services Nutritional Counseling Prosthetic Devices Radiation Reconstructive Surgery Transplant Treatment for Temporomandibular Joint Disorders Well Baby Visits and Care Clinical Trials Off Label Prescription Drugs Prescription Drugs Other Wigs Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Mental/Behavioral Health Emergency Room Mental/Behavioral Health Emergency Transportation/Ambulance Mental/Behavioral Health ER Physician Fee Mental/Behavioral Health Outpatient Other Services Mental/Behavioral Health Urgent Care Substance Use Disorder Emergency Room Substance Use Disorder Emergency Transportation/Ambulance Substance Use Disorder ER Physician Fee Substance Use Disorder Outpatient Other Services Substance Use Disorder Urgent Care Telehealth and Virtual Care
More Limited Benefits	Preventive Care/Screening/Immunization Skilled Nursing Facility Hearing Aids Home Health Care Services Outpatient Rehabilitation Services Habilitation Services Chiropractic Care Rehabilitative Occupational and Rehabilitative Physical Therapy Rehabilitative Speech Therapy
More Excluded Benefits	Acupuncture Cosmetic Surgery Infertility Treatment Weight Loss Programs Dental Check-Up for Children Abortion for Which Public Funding is Prohibited Long-Term/Custodial Nursing Home Care

Exclusions and Limitations

More Included Benefits

Other Practitioner Office Visit (Nurse, Physician Assistant)
Bariatric Surgery
Private-Duty Nursing
Imaging (CT/PET Scans, MRIs)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Inpatient Physician and Surgical Services
Durable Medical Equipment
Hospice Services
Routine Foot Care
Diabetes Care Management
Inherited Metabolic Disorder - PKU
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Nutritional Counseling
Prosthetic Devices
Radiation
Reconstructive Surgery
Transplant
Treatment for Temporomandibular Joint Disorders
Well Baby Visits and Care
Clinical Trials
Off Label Prescription Drugs
Prescription Drugs Other
Wigs
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Mental/Behavioral Health Emergency Room
Mental/Behavioral Health Emergency Transportation/Ambulance
Mental/Behavioral Health ER Physician Fee
Mental/Behavioral Health Outpatient Other Services
Mental/Behavioral Health Urgent Care
Substance Use Disorder Emergency Room
Substance Use Disorder Emergency Transportation/Ambulance
Substance Use Disorder ER Physician Fee
Substance Use Disorder Outpatient Other Services
Substance Use Disorder Urgent Care
Telehealth and Virtual Care

More Limited Benefits

Preventive Care/Screening/Immunization
Skilled Nursing Facility
Hearing Aids
Home Health Care Services
Outpatient Rehabilitation Services
Habilitation Services
Chiropractic Care
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy

More Excluded Benefits

Acupuncture
Cosmetic Surgery
Infertility Treatment
Weight Loss Programs
Dental Check-Up for Children
Abortion for Which Public Funding is Prohibited
Long-Term/Custodial Nursing Home Care

Premium	Plan Name	Deductible
from $347	Cigna Connect 8000	$8,000.00	Select
from $355	Ambetter Essential Care 5 (2021) + Vision + Adult Dental	$8,100.00	Select
from $412	Ambetter Essential Care 1 (2021)	$8,300.00	Select
from $432	Ambetter Essential Care 1 (2021) + Vision + Adult Dental	$8,300.00	Select

Premium

Plan Name

Deductible

from $347

Cigna Connect 8000

$8,000.00

Select

from $355

Ambetter Essential Care 5 (2021) + Vision + Adult Dental

$8,100.00

Select

from $412

Ambetter Essential Care 1 (2021)

$8,300.00

Select

from $432

Ambetter Essential Care 1 (2021) + Vision + Adult Dental

$8,300.00

Select

Last Name

Location/Distance

Please select the correct zip

Rajesh, Khona

Kita, Patel

William, Shea

Timothy, Graham

Jay, Eldridge

Donald, Runyan

Shawn, Hermenau

Sw Rehab

Nicolas, Santos

Nnabuikem, Anaba

Kailey, Rote

Joseph, Sanchez

Michael, Mccullagh

Zachary, Parkinson

Shanti Anesthesiology, Pllc

Nafisah, Naqvi

Stephanie, Clark

Mina, Tawadrous

Lee, Barnwell

Marjorie, Bacon

Jennifer, Mccumbee

James, Lavin

Kemell Health Llc

Southwestern Palliative Care Associates Plc

View All Details

Rajesh Khona, M.D.

View All Details

Phone Number
(602) 273-6770
Office Locations
2400 S Avenue A
Yuma, AZ 85364

Zip Code	85364 (edit)
Applicant	1/17/1986 Male (edit)

Insurance Type	ACA (Obamacare)
Plan Name	Ambetter Essential Care 5 (2021)
Plan ID	hhs-91450AZ0080119
Plan Year	2021
Insurance Provider	Health Net
Metal Level	Expanded Bronze
Plan Type	HMO
Deductible	$8,100
Out-of-Pocket Maximum	$8,500
Plan Highlights

Zip Code	85364 (edit)
Applicant	1/17/1986 Male (edit)

Ambetter Essential Care 5 (2021)

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Benefits & Coverage

Costs for Medical Care

Prescription drug coverage

Access to doctors and hospitals

Hospital services

Maternity

Mental Health

Medical Management Programs

Vision Coverage

Child Dental Coverage

Adult Dental Coverage

Exclusions and Limitations

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