Gold Elite+Dental 4 $0 Tier-1 PCP Visits, $0 Antidote 24/7 Virtual PCP/Urg/Chronic Care/Referred Labs, $0 Advanced Rx
Antidote Health Plan of Ohio, Inc. · 2026 plan year
Gold
- Ind. deductible
- $3,000
- Family deductible
- $6,000
- Ind. OOP max
- $9,000
- Family OOP max
- $18,000
Compare with other Gold plans in OH
Side by side: deductibles, out-of-pocket limits and copays.
Other cost-sharing reduction variants for this plan:
More Antidote Health Plan of Ohio, Inc. plans in OH
Monthly premiums by age
Rating Area 12 — the lowest-priced of the 15 areas this plan covers. Premiums differ by area.
| Age | Individual | Individual + tobacco |
|---|---|---|
| Under 15 | $426 | $426 |
| 21 | $557 | $641 |
| 30 | $632 | $727 |
| 40 | $712 | $819 |
| 50 | $995 | $1,144 |
| 60 | $1,512 | $1,739 |
| 64 and over | $1,671 | $1,922 |
Live premium estimate
Benefits & cost sharing
Primary Care
| Benefit | In-network |
|---|---|
| Preventive Care/Screening/Immunization | No charge |
| Primary Care Visit to Treat an Injury or Illness | No charge |
Specialist
| Benefit | In-network |
|---|---|
| Specialist Visit | $25.00 |
Hospital
| Benefit | In-network |
|---|---|
| Emergency Room Services | 20.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay) | 20.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services | 20.00% Coinsurance after deductible |
| Urgent Care Centers or Facilities | 20.00% Coinsurance after deductible |
Pharmacy
| Benefit | In-network |
|---|---|
| Generic Drugs | $5.00 |
| Non-Preferred Brand Drugs | 20.00% Coinsurance after deductible |
| Preferred Brand Drugs | $30.00 |
| Specialty Drugs | 20.00% Coinsurance after deductible |
Mental Health
| Benefit | In-network |
|---|---|
| Mental/Behavioral Health Inpatient Services | 20.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services | No charge |
Other
| Benefit | In-network |
|---|---|
| Abortion for Which Public Funding is Prohibited | Not covered |
| Accidental Dental | 20.00% Coinsurance after deductible |
| Acupuncture | Not covered |
| Allergy Testing | 20.00% Coinsurance after deductible |
| Bariatric Surgery | Not covered |
| Basic Dental Care - Adult | 50.00% Coinsurance after deductible |
| Basic Dental Care - Child | 50.00% Coinsurance after deductible |
| Chemotherapy | 20.00% Coinsurance after deductible |
| Chiropractic Care | No charge |
| Cosmetic Surgery | Not covered |
| Delivery and All Inpatient Services for Maternity Care | 20.00% Coinsurance after deductible |
| Dental Check-Up for Children | 50.00% Coinsurance after deductible |
| Diabetes Education | 20.00% Coinsurance after deductible |
| Dialysis | 20.00% Coinsurance after deductible |
| Durable Medical Equipment | 20.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance | 20.00% Coinsurance after deductible |
| Eye Glasses for Children | No charge |
| Habilitation Services | 20.00% Coinsurance after deductible |
| Hearing Aids | Not covered |
| Home Health Care Services | 20.00% Coinsurance after deductible |
| Hospice Services | 20.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs) | 20.00% Coinsurance after deductible |
| Infertility Treatment | 20.00% Coinsurance after deductible |
| Infusion Therapy | 20.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services | 20.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services | $25.00 |
| Long-Term/Custodial Nursing Home Care | Not covered |
| Major Dental Care - Adult | 50.00% Coinsurance after deductible |
| Major Dental Care - Child | 50.00% Coinsurance after deductible |
| Nutritional Counseling | 20.00% Coinsurance after deductible |
| Orthodontia - Adult | Not covered |
| Orthodontia - Child | 50.00% Coinsurance after deductible |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | No charge |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | 20.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services | 20.00% Coinsurance after deductible |
| Prenatal and Postnatal Care | 20.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services | No charge |
| Private-Duty Nursing | 20.00% Coinsurance after deductible |
| Prosthetic Devices | 20.00% Coinsurance after deductible |
| Radiation | $25.00 |
| Reconstructive Surgery | 20.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | No charge |
| Rehabilitative Speech Therapy | $50.00 |
| Routine Dental Services (Adult) | Not covered |
| Routine Eye Exam (Adult) | Not covered |
| Routine Eye Exam for Children | No charge |
| Routine Foot Care | Not covered |
| Skilled Nursing Facility | 20.00% Coinsurance after deductible |
| Substance Abuse Disorder Inpatient Services | 20.00% Coinsurance after deductible |
| Transplant | 20.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders | 20.00% Coinsurance after deductible |
| Weight Loss Programs | Not covered |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | 20.00% Coinsurance after deductible |
Plan rules
Service area
This plan covers 51 geographic areas.
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