AultCare Bronze 5000 Select No Pediatric Dental
| Plan Type: | PPO |
| Plan Tier: | Expanded Bronze |
| Medical Deductible - Individual: | $5,000 |
| Medical Deductible - Family: | $10,000 |
| Drug Deductible - Individual: | Included in Medical |
| Drug Deductible - Family: | Included in Medical |
| Out of Pocket Max - Individual: | $6,550 |
| Out of Pocket Max - Family: | $13,100 |
| Primary Care Visit: | 35% Coinsurance after deductible |
| Specialist Visit: | 35% Coinsurance after deductible |
| Emergency Room: | 35% Coinsurance after deductible |
| Hospital - Physician: | 35% Coinsurance after deductible |
| Hospital - Facility: | 35% Coinsurance after deductible |
| Link to Full SBC: | http://www.aultcas.com/Application/na/getForm.aspx?sbc=sbc6642019.pdf |
| Plan Brochure: | http://www.aultcas.com/Application/na/getForm.aspx?sbcbroc=brochure6642019.pdf |
Other Coverage:
| Child Dental: | No |
| Adult Dental | No |
Prescription Drug Pricing:
| Generic Drugs: | 35% Coinsurance after deductible |
| Non-Preferred Brand Drugs: | 35% Coinsurance after deductible |
| Preferred Brand Drugs: | 35% Coinsurance after deductible |
| Specialty Drugs: | 35% Coinsurance after deductible |
| Link to Full Policy Formulary: | http://www.AultCAS.com/acformularyb2019.aspx |
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