AultCare Gold 1200 Select No Pediatric Dental
| Plan Type: | PPO |
| Plan Tier: | Gold |
| Medical Deductible - Individual: | $1,200 |
| Medical Deductible - Family: | $2,400 |
| Drug Deductible - Individual: | $0 |
| Drug Deductible - Family: | $0 |
| Out of Pocket Max - Individual: | $5,800 |
| Out of Pocket Max - Family: | $11,600 |
| Primary Care Visit: | $20 |
| Specialist Visit: | $40 |
| Emergency Room: | 10% Coinsurance after deductible |
| Hospital - Physician: | 10% Coinsurance after deductible |
| Hospital - Facility: | 10% Coinsurance after deductible |
| Link to Full SBC: | http://www.aultcas.com/Application/na/getForm.aspx?sbc=sbc6562019.pdf |
| Plan Brochure: | http://www.aultcas.com/Application/na/getForm.aspx?sbcbroc=brochure6562019.pdf |
Other Coverage:
| Child Dental: | No |
| Adult Dental | No |
Prescription Drug Pricing:
| Generic Drugs: | $10 |
| Non-Preferred Brand Drugs: | 40% |
| Preferred Brand Drugs: | 30% |
| Specialty Drugs: | 50% |
| Link to Full Policy Formulary: | http://www.AultCAS.com/acformularya2019.aspx |
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