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Elite Gold + Vision + Adult Dental
Health Insurance Plan Details (2025 Plan)
by Ambetter from Sunflower Health Plan
Monthly Premium
EPO
$ubsidy
Gold
- Deductible
- $0 /yr
- Max Out-of-Pocket
- $5,500 /yr
Details
| Deductible (per individual) | $0 /yr |
| Deductible (per family) | $0 /yr |
| Max Out-of-Pocket (per individual) | $5,500 /yr |
| Max Out-of-Pocket (per family) | $11,000 /yr |
| Drug Deductible (per individual) | Included in Medical |
| Drug Deductible (per family) | Included in Medical |
| Drug Max Out-of-Pocket (per individual) | Included in Medical |
| Drug Max Out-of-Pocket (per family) | Included in Medical |
| Plan Type | EPO |
| Includes Child Dental? | No |
| Includes Adult Dental? | Yes |
Out-of-Pocket Costs
| Preventive Care | No Charge |
| Primary Care Visit | $5 Copay |
| Specialist Visit | $60 Copay |
| Emergency Room | 30% Coinsurance |
| Inpatient Facility | 30% Coinsurance |
| Inpatient Physician | 30% Coinsurance |
| Generic Drugs | $3 Copay |
| Preferred Brand Drugs | $50 Copay |
| Non-preferred Brand Drugs | 45% Coinsurance |
| Specialty Drugs | 50% Coinsurance |
Plan Documents
| Summary of Benefits and Coverage | SBC doc |
| Provider Directory | Doctor lookup |
| Drug Formulary List | drug list |
* Figures shown are only for in-network medical costs
** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible
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