Silver AH

Arkansas Blue Cross and Blue Shield

Silver

Ind. deductible: $6,350
Family deductible: $6,350
Ind. OOP max: $6,550
Family OOP max: $6,550

Other cost-sharing reduction variants for this plan:

73% AV Level Silver Plan 87% AV Level Silver Plan 94% AV Level Silver Plan Limited Cost Sharing Plan Variation Standard Silver Off Exchange Plan Zero Cost Sharing Plan Variation

Monthly premiums by age

Age	Individual	Individual + tobacco
21	$629	—
30	$714	—
40	$804	—
50	$1,123	—
60	$1,707	—

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	$5.00 Copay after deductible

Specialist

Benefit	In-network
Specialist Visit	$45.00 Copay after deductible

Hospital

Benefit	In-network
Emergency Room Services	$200.00 Copay after deductible
Inpatient Hospital Services (e.g., Hospital Stay)	$200.00 Copay per Day after deductible
Outpatient Surgery Physician/Surgical Services	$45.00 Copay after deductible
Urgent Care Centers or Facilities	$0.00

Pharmacy

Benefit	In-network
Generic Drugs	$100.00
Non-Preferred Brand Drugs	$2,000.00
Off Label Prescription Drugs	30.00% Coinsurance after deductible
Preferred Brand Drugs	$1,000.00
Preventive Drugs	No charge
Specialty Drugs	$0.00
Specialty Drugs Tier 2	$2,650.00

Mental Health

Benefit	In-network
Mental/Behavioral Health Inpatient Services	$200.00 Copay per Day after deductible
Mental/Behavioral Health Outpatient Services	$5.00 Copay after deductible

Other

Benefit	In-network
Abortion for Which Public Funding is Prohibited	Not covered
Accidental Dental	No Charge after deductible
Acquired Brain Injury	30.00% Coinsurance after deductible
Acupuncture	Not covered
Allergy Testing	No Charge after deductible
Applied Behavior Analysis Based Therapies	30.00% Coinsurance after deductible
Bariatric Surgery	30.00% Coinsurance after deductible
Basic Dental Care - Adult	Not covered
Basic Dental Care - Child	Not covered
Biomarke	30.00% Coinsurance after deductible
Chemotherapy	No Charge after deductible
Chiropractic Care	$5.00 Copay after deductible
Cochlear Implants	No Charge after deductible
Community Health Worke	30.00% Coinsurance after deductible
Cosmetic Surgery	Not covered
Craniofacial Surgery	No Charge after deductible
Delivery and All Inpatient Services for Maternity Care	No Charge after deductible
Dental Anesthesia	30.00% Coinsurance after deductible
Dental Check-Up for Children	Not covered
Diabetes Care Management	30.00% Coinsurance after deductible
Diabetes Education	No charge
Dialysis	No Charge after deductible
Doulas	No Charge after deductible
Durable Medical Equipment	$200.00 Copay after deductible
Emergency Transportation/Ambulance	30.00% Coinsurance after deductible
Eye Glasses for Children	30.00% Coinsurance after deductible
Gastric Electrical Stimulation	No Charge after deductible
Genetic Testing for Cance	No charge
Habilitation Services	$4.70
Hearing Aids	80.00%
Home Health Care Services	30.00% Coinsurance after deductible
Hospice Services	No Charge after deductible
Imaging (CT/PET Scans, MRIs)	$4.70
Infertility Treatment	$0.00
Infusion Therapy	30.00% Coinsurance after deductible
Inherited Metabolic Disorder - PKU	30.00% Coinsurance after deductible
Inpatient Physician and Surgical Services	No Charge after deductible
Laboratory Outpatient and Professional Services	$5.00
Long-Term/Custodial Nursing Home Care	Not covered
Lung Cancer Screening	No charge
Major Dental Care - Adult	Not covered
Major Dental Care - Child	Not covered
Nutritional Counseling	No Charge after deductible
Orthodontia - Adult	Not covered
Orthodontia - Child	Not covered
Other Practitioner Office Visit (Nurse, Physician Assistant)	$30.00 Copay after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)	$4.70 Copay after deductible
Outpatient Rehabilitation Services	$0.00
PANS/PANDA	30.00% Coinsurance after deductible
Prenatal and Postnatal Care	No Charge after deductible
Private-Duty Nursing	Not covered
Prosthetic Devices	30.00% Coinsurance after deductible
Radiation	No Charge after deductible
Reconstructive Surgery	No Charge after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy	$4.70
Rehabilitative Speech Therapy	$30.00 Copay after deductible
Restorative Reproductive Treatment	30.00% Coinsurance after deductible
Routine Dental Services (Adult)	Not covered
Routine Eye Exam (Adult)	Not covered
Routine Eye Exam for Children	No charge
Routine Foot Care	30.00% Coinsurance after deductible
Skilled Nursing Facility	$200.00 Copay per Day after deductible
Substance Abuse Disorder Inpatient Services	$200.00 Copay per Day after deductible
Substance Abuse Disorder Outpatient Services	$4.70
Transplant	No Charge after deductible
Treatment for Temporomandibular Joint Disorders	No Charge after deductible
Weight Loss Programs	Not covered
Weight Loss Treatment	No Charge after deductible
Well Baby Visits and Care	No charge
Well Child Care	No charge
X-rays and Diagnostic Imaging	$4.70

Plan rules

Service area

This plan covers 1 geographic area.