Ohio health plan · 2025

AultCare Gold 1100 Select No Pediatric Dental · 28162OH0060054

AultCare Insurance Company offers this marketplace health insurance plan (Plan ID 28162OH0060054) so you can compare premiums, coverage levels, and provider access against other health plan insurance options. Use the modules below to decide whether this is the best health insurance plan for your household or if another insurance health plan fits better.

Metal level: Gold Plan type: PPO CSR: Standard Gold On Exchange Plan Issuer: AultCare Insurance Company
Telehealth Data pending HSA eligible No Dental Not listed Vision Child
Pay / Manage Plan View issuer site

CMS AV Calculator output: 81.17% (18.83% member share on average). Learn about AV methodology.

2025 cost summary

Key premiums & cost sharing

Rates mirror the latest CMS import (Tue, 02 Dec 2025 06:13 GMT). Personalize costs with your ZIP, age, and subsidies in the plan finder.

Monthly premium

$427 – $1868

Before subsidies

Estimate after subsidies

Deductible

N/A

N/A

See deductible details

Max out-of-pocket

$6,900

$13800 per group

Review MOOP rules

Office visits

Primary care $25.00
Specialist $45.00
HSA Not eligible

Drug tiers

Generic $10.00
Preferred brand 30.00%

View formulary tiers

$622 / mo before subsidies

≈ $7459 per year before tax credits.

Start with this unsubsidized premium, then apply marketplace tax credits to see your final monthly payment.

  • Ideal for shoppers comparing Bronze vs. Silver budgets.
  • Update your Marketplace application to apply premium tax credits.

$1852 / mo before subsidies

≈ $22220 per year before tax credits.

Pre-subsidy rate for a couple with one dependent. Switch to Silver CSR plans if you qualify to reduce these numbers.

  • Compares well against PPO vs HMO networks when planning for childcare and telehealth needs.
  • CSR savings require a Silver variant. Use the plan finder to load Silver options if you need lower deductibles.

$2243 / mo before subsidies

≈ $26910 per year before tax credits.

Pairs with cost-sharing reductions (CSR) when you select a Silver tier and qualify based on income.

  • Use this estimate before adding childcare, dental, or vision extras.
  • CSR Silver variants can lower deductibles dramatically for eligible incomes.
  • CSR savings require a Silver variant. Use the plan finder to load Silver options if you need lower deductibles.

$1425 / mo before subsidies

≈ $17102 per year before tax credits.

Shows the combined pre-subsidy rate for two adults. Add dependents or subsidies in your application to refine it.

  • Great for households deciding between PPO and HMO networks.
  • Telehealth and HSA perks (when offered) apply to both members.
Issuer profile See benefits

Preventive Care/Screening/Immunization

0.00%

Emergency Room Services

20.00% Coinsurance after deductible

Durable Medical Equipment

20.00% Coinsurance after deductible

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Enrollment guidance

Stay on top of 2025 ACA deadlines

Open Enrollment window

Marketplace enrollment for 2025 coverage typically runs Nov 1 – Jan 15 (dates may vary slightly in Ohio). Submit changes before the deadline to avoid a coverage gap.

  • Enroll by Dec 15 for Jan 1 starts.
  • Finalize plan switches before the window closes.

Special Enrollment Periods

You can change plans mid-year if you experience a qualifying life event (move, childbirth, marriage, loss of other coverage).

  • Report the event within 60 days.
  • Keep documentation handy for Healthcare.gov or your state exchange.

CSR & subsidy reminders

Premium tax credits and cost-sharing reductions (CSR) update annually when you re-submit your marketplace application.

  • Enter accurate income to maximize Advanced Premium Tax Credits.
  • Standard Gold On Exchange Plan plans like this one keep deductibles and copays lower if you qualify.

Thinking about switching?

Before you leave your current plan, compare networks, drug coverage, and total cost using the cards on this page.

  • Match provider networks so ongoing care isn’t disrupted.
  • Confirm prescriptions stay on-formulary or budget for tier changes.

Top covered benefits

How this plan handles key care scenarios

Preventive Care/Screening/Immunization

0.00%

Emergency Room Services

20.00% Coinsurance after deductible

Durable Medical Equipment

20.00% Coinsurance after deductible

Premium snapshot

Plan identifiers & filings

Track the official identifiers, documents, and filing dates tied to this plan. Open the marketing or formulary links whenever you need the latest PDF from the issuer.

Plan ID 28162OH0060054
Coverage year 2025
State Ohio
Issuer AultCare Insurance Company
Formulary document Download formulary
Marketing materials View marketing kit
Variant ID 28162OH0060054-01
Available variants

Standard Off Exchange Plan · 28162OH0060054-00

Standard On Exchange Plan · 28162OH0060054-01

Open to Indians below 300% FPL · 28162OH0060054-02

Open to Indians above 300% FPL · 28162OH0060054-03
Last plan update Thu, 10 Oct 2024 00:00 GMT
Last HealthPorta import Tue, 02 Dec 2025 06:13 GMT

Network stats

Provider access snapshot

Review the network branding plus the number of in-network clinicians we track from issuer filings. Counts update with each CMS import (Tue, 02 Dec 2025 06:13 GMT).

All providers in Ohio 15556
PCPs in Ohio 2657
Telehealth support Data pending
Nationwide providers 17242
15,556 doctors statewide 2,657 PCPs 108 OB/GYN

Provider network(s)

Providers Ohio All US states
All 15556 17242
PCP 2657 2963
Allergy 5 5
OB/GYN 108 126
Dentists 8 8

Drug coverage overview

3,553 drugs tracked

Inspect tier distribution plus authorization, step therapy, and quantity-limit counts sourced from HealthPorta’s formulary import.

Tier Covered drugs
NON-PREFERRED-GENERIC 2,297
GENERIC-PREVENTIVE 386
NON-PREFERRED-BRAND 380
PREFERRED-BRAND-SPECIALTY 318
GENERIC-SPECIALTY 172
Prior authorization Drugs
Required 490
Not Required 3,063
Step therapy Drugs
Required 153
Not Required 3,400
Quantity limits Drugs
Has Limit 1,197
No Limit 2,356

Customer highlights

What stands out for members

  • Issuer: AultCare Insurance Company · Plan ID 28162OH0060054 · 2025 filing.
  • Disease management programs available: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs.
  • Download the latest formulary directly from the issuer here.
  • Review marketing brochures and SBC PDFs via the issuer marketing repository.
  • Variant 28162OH0060054-01 (Standard On Exchange Plan) currently displayed.
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Benefits

Covered services & limitations

Everyday care

Office visits, preventive care, labs, imaging, and home health.

Chiropractic Care

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

Limit: 12.0 Treatment(s) per Year

Benefit limit applies for Osteopathic/Chiropractic Manipulation Therapy.

Exclusions: nan

Diabetes Education

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

Diabetes Self-Management Training for an individual with insulin dependent diabetes, non-insulin dependent diabetes, or elevated blood glucose levels induced by pregnancy or another medical condition.

Exclusions: nan

Home Health Care Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

Limit: 100.0 Visit(s) per Year

When therapy services are provided in the home (including physical, speech, and occupational therapy) as part of home health care services, they are not subject to separate visit limits for therapy services. The 100 visit/year limit is also not applicable to home infusion therapy or private duty nursing rendered in the home setting.

Exclusions: nan

Laboratory Outpatient and Professional Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

nan

Exclusions: nan

Other Practitioner Office Visit (Nurse, Physician Assistant)

$25.00
Tier 1 in-network $25.00
Out-of-network 40.00% Coinsurance after deductible

Other Practitioner Visit benefits and member cost share apply to services in a telehealth setting

Exclusions: nan

Preventive Care/Screening/Immunization

0.00%
Tier 1 in-network 0.00%
Out-of-network 40.00% Coinsurance after deductible

Services with an 'A' or 'B' rating from the United States Preventive Services Task Force (USPSTF); Immunizations for children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; Preventive care and screenings for infants, children and adolescents as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Additional preventive care and screening for women provided for in the guidelines supported by the Health Resources and Services Administration including: women's contraceptives, sterilization procedures, and counseling; breastfeeding support, supplies, and counseling (benefits for breast pumps are limited to one pump per benefit period); and gestational diabetes screening; routine screening mammograms; routine cytologic screening; child health supervision services from birth to age 9.

Exclusions: nan

Primary Care Visit to Treat an Injury or Illness

$25.00
Tier 1 in-network $25.00
Out-of-network 40.00% Coinsurance after deductible

Primary Care Visit benefits and member cost share apply to services in a telehealth setting. Primary Care Visit benefits and member cost share apply to Mental Health and Substance Abuse services in an office or telehealth setting.

Exclusions: nan

Rehabilitative Occupational and Rehabilitative Physical Therapy

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

Limit: 40.0 Visit(s) per Year

Physical and Occupational Therapy limited to 40 visits combined per benefit period.

Exclusions: nan

Rehabilitative Speech Therapy

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

Limit: 20.0 Visit(s) per Year

nan

Exclusions: nan

Specialist Visit

$45.00
Tier 1 in-network $45.00
Out-of-network 40.00% Coinsurance after deductible

Specialist Visit benefits and member cost share apply to services in a telehealth setting

Exclusions: nan

Urgent Care Centers or Facilities

$75.00
Tier 1 in-network $75.00
Out-of-network $75.00

nan

Exclusions: nan

X-rays and Diagnostic Imaging

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

nan

Exclusions: nan

Hospital & urgent

Emergency room, inpatient stays, ambulance, and surgeries.

Chemotherapy

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

nan

Exclusions: nan

Delivery and All Inpatient Services for Maternity Care

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

Coverage for the Inpatient postpartum stay for mother and newborn child in a hospital will be, at a minimum, 48 hours for a vaginal delivery and 96 hours for a cesarean section. Coverage will be for the length of stay recommended by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists in their Guidelines for Prenatal Care.

Exclusions: nan

Dialysis

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

Benefits include supportive use of an artificial kidney machine.

Exclusions: nan

Durable Medical Equipment

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

Covered services include durable medical equipment, medical devices and supplies, prosthetics and appliances, including cochlear implants and eyeglasses/contact lenses (for cataract surgery or injury), and medical/surgical supplies and equipment that serve only a medical purpose for the management of disease. Benefit limits: Wigs are limited to the first one following cancer treatment not to exceed one per Benefit Period; limit of four (4) surgical bras following mastectomy per benefit period; (as required by the Women's Health and Cancer Rights Act); Left Ventricular Artificial Devices (LVAD) covered only as bridge to heart transplant.

Exclusions: nan

Emergency Room Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

nan

Exclusions: nan

Emergency Transportation/Ambulance

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 20.00% Coinsurance after deductible

Ambulance Services are transportation by a vehicle (including ground, water, fixed wing and rotary wing air transportation) designed, equipped and used only to transport the sick and injured and staffed by Emergency Medical Technicians (EMT), paramedics, or other certified medical professionals: from home, scene of accident or medical emergency to a hospital; between hospitals; between a hospital and skilled nursing facility; or from a hospital or skilled nursing facility to home; ambulance trips must be made to the closest facility that can give covered services appropriate for the member's condition.

Exclusions: nan

Hospice Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

To be eligible for Hospice benefits, the patient must have a limited life expectancy, as confirmed by the attending Physician.

Exclusions: nan

Inpatient Hospital Services (e.g., Hospital Stay)

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

There are specific exceptions to certain exclusions and/or additional exclusions that are detailed in plan document; inpatient hospital services include charges from a hospital, skilled nursing facility or other provider for room, board, general nursing services; and ancillary (related) services.

Exclusions: nan

Inpatient Physician and Surgical Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

There are specific exceptions to certain exclusions and/or additional exclusions that are detailed in plan document; inpatient medical care visits limited to one visit per day by any one physician.

Exclusions: nan

Mental/Behavioral Health Inpatient Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.

Exclusions: nan

Mental/Behavioral Health Outpatient Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. The cost sharing that displays applies to outpatient facility services only. All other outpatient services [e.g., office visit, office therapy] may be subject to the Primary Care Visit copayment. Please refer to the plan policy documents for detailed information.

Exclusions: nan

Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

See specific exceptions to these exclusions and/or additional exclusions that are detailed in plan document; benefits for facility charges for Outpatient Services are payable for the removal of teeth or for other dental processes only if the patient's medical condition or the dental procedure requires a Hospital setting to ensure the safety of the patient

Exclusions: nan

Outpatient Rehabilitation Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

Limit: 116.0 Visit(s) per Year

Therapy Services rendered in the home as part of Home Care Services will be subject to the Home Care Services visit limits; outpatient rehabilitation services visit limits will not apply. If different types of Therapy Services are performed during one Physician Home Visit, Office Service, or Outpatient Service, then each different type of Therapy Service performed will be considered a separate Therapy Visit. Each Therapy Visit will count against the applicable maximum visits per Benefit Period listed below: Physical and Occupational Therapy limited to 40 visits combined. Speech Therapy limited to 20 visits. Cardiac Rehabilitation limited to 36 visits. Pulmonary Rehabilitation limited to 20 visits, except if rendered as part of Physical Therapy, the Physical Therapy visit limit will apply. Benefit also includes Physical Medicine and Rehabilitation Day Rehabilitation Therapy services on an Outpatient basis. Limited to a combined 60 days per Year maximum for both Inpatient and outpatient day rehabilitation therapy services.

Exclusions: nan

Outpatient Surgery Physician/Surgical Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

See specific exceptions to these exclusions and/or additional exclusions that are detailed in plan document.

Exclusions: nan

Radiation

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

nan

Exclusions: nan

Skilled Nursing Facility

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

Limit: 90.0 Days per Year

Benefits include Items and services provided as an inpatient in a skilled nursing bed of skilled nursing facility or hospital, including room and board in semi-private accommodations; rehabilitative services; and drugs, biologicals, and supplies furnished for use in the skilled nursing facility and other medically necessary services and supplies.

Exclusions: nan

Substance Abuse Disorder Inpatient Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008.

Exclusions: nan

Substance Abuse Disorder Outpatient Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

Coverage and limits must comply with state mandates and the parity standards set forth in the federal Mental Health Parity and Addiction Equity Act of 2008. The cost sharing that displays applies to outpatient facility services only. All other outpatient services [e.g., office visit, office therapy] may be subject to the Primary Care Visit copayment. Please refer to the plan policy documents for detailed information.

Exclusions: nan

Transplant

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

Includes coverage for unrelated donor search services ($30,000 per transplant/network & Non network combined) and travel/lodging as approved by the plan ($10,000 per transplant/network & Non network combined). Transplant benefits apply to any medically necessary human organ and stem cell/bone marrow transplants and transfusions including necessary acquisition procedures, harvest and storage, necessary preparatory myeloablative therapy, and initial evaluation/testing to determine eligibility as a transplant candidate.

Exclusions: nan

Pregnancy & family

Maternity, newborn, pediatric dental and vision extras.

Basic Dental Care - Child

Coverage details pending

nan

Exclusions: nan

Hearing Aids

Coverage details pending

nan

Exclusions: nan

Major Dental Care - Child

Coverage details pending

nan

Exclusions: nan

Prenatal and Postnatal Care

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

Cost sharing does not apply to certain preventive services. Depending on the type of service, a copayment, deductible, or coinsurance may apply. Includes post-delivery follow-up care performed, by a physician or nurse, within 72 hours of discharge, through home health care visits or, at patient's discretion, in a medical setting. This coverage includes, but is not limited to parent education; assistance and training in breast or bottle feeding; and routine maternal or neonatal tests and screening (including collection of sample for hereditary and metabolic newborn screening).

Exclusions: nan

Routine Eye Exam for Children

0.00%
Tier 1 in-network 0.00%
Out-of-network 40.00% Coinsurance after deductible

Limit: 1.0 Exam(s) per Year

Coverage includes benefits specified in the FEDVIP FEP Blue Vision - High Option plan, including low vision benefits.

Exclusions: nan

Well Baby Visits and Care

0.00%
Tier 1 in-network 0.00%
Out-of-network 40.00% Coinsurance after deductible

nan

Exclusions: nan

Pharmacy & drugs

Generic, brand, specialty, and mail order tiers.

Generic Drugs

$10.00
Tier 1 in-network $10.00
Out-of-network $10.00

Preventive Maintenance Tier 1 drugs are covered up to a 60-day supply with no cost share, including over-the-counter drugs, stop smoking aids, and nutritional or dietary supplements required by Preventive/Screening/Immunization benefits. Generic Tier 2 drugs are covered for a 34-day supply with a $10 Copayment or 20% Coinsurance, whichever is greater, or up to a 60-day supply with a $30 Copayment or 20% Coinsurance, whichever is greater. Non-Preferred Generic Tier 3 drugs are covered with $20 Copayment or 30% Coinsurance, whichever is greater. Non-Preferred Generic Tier 4 drugs are covered with $45 Copayment or 40% Coinsurance, whichever is greater.

Exclusions: nan

Non-Preferred Brand Drugs

40.00%
Tier 1 in-network 40.00%
Out-of-network 40.00%

Non-Preferred Brand Tier 4 drugs are covered with $45 Copayment or 40% Coinsurance, whichever is greater.

Exclusions: nan

Preferred Brand Drugs

30.00%
Tier 1 in-network 30.00%
Out-of-network 30.00%

Preferred Brand Tier 3 drugs are covered with $20 Copayment or 30% Coinsurance, whichever is greater.

Exclusions: nan

Specialty Drugs

50.00%
Tier 1 in-network 50.00%
Out-of-network 50.00%

Preferred Generic Specialty Tier 5 drugs are covered with $10 Copayment or 20% Coinsurance, whichever is greater. Preferred Brand Specialty Tier 6 drugs are covered with $50 Copayment or 50% Coinsurance, whichever is greater. Specialty drugs can only be purchased with a one-month supply through mail order only using a contracted AultCare Specialty network pharmacy.

Exclusions: Specialty drugs exclude purchases through retail pharmacies. Specialty drugs can only be purchased with a one-month supply through mail order only using a contracted AultCare Specialty network pharmacy.

Wellness & extras

Vision, dental, therapies, prosthetics, weight management.

Accidental Dental

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

Limit: 3000.0 Dollars per Episode

Quantitative Limit represents established actuarial equivalent of benchmark plan annual dollar limits. Annual and lifetime dollar limits will no longer apply. Coverage for dental services resulting from an accidental injury when treatment is performed within 12 months after the injury. The benefit limit will not apply to outpatient facility charges, anesthesia billed by a provider other than the physician performing the service, or to covered services required by law; coverage includes oral examinations, x-rays, tests and laboratory examinations, restorations, prosthetic services, oral surgery, mandibular/maxillary reconstruction, anesthesia and include facility charges for outpatient services for the removal of teeth or for other dental processes if the patient's medical condition or the dental procedure requires a hospital setting to ensure the safety of the patient.

Exclusions: nan

Basic Dental Care - Adult

Coverage details pending

nan

Exclusions: nan

Dental Check-Up for Children

Coverage details pending

nan

Exclusions: nan

Infusion Therapy

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

Home IV therapy includes but is not limited to: injections (intra-muscular, subcutaneous, continuous subcutaneous), Total Parenteral Nutrition (TPN), Enteral nutrition therapy, antibiotic therapy, pain management and chemotherapy.

Exclusions: nan

Major Dental Care - Adult

Coverage details pending

nan

Exclusions: nan

Nutritional Counseling

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

Covered benefit under home health services and covered as USPSTF A or B recommendation under preventive health services (includes diet counseling for adults at higher risk for chronic disease, obesity screening and counseling for all adults, and healthy diet counseling for adults with cardiovascular risk factors).

Exclusions: nan

Orthodontia - Adult

Coverage details pending

nan

Exclusions: nan

Orthodontia - Child

Coverage details pending

nan

Exclusions: nan

Prosthetic Devices

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

Benefits for artificial substitutes for body parts and tissues and materials inserted into tissue for functional or therapeutic purposes. Covered Services include purchase, fitting, needed adjustment, repairs, and replacements of prosthetic devices and supplies that 1) Replace all or part of a missing body part and its adjoining tissues; or 2) Replace all or part of the function of a permanently useless or malfunctioning body part.

Exclusions: nan

Routine Dental Services (Adult)

Coverage details pending

nan

Exclusions: nan

Weight Loss Programs

Coverage details pending

nan

Exclusions: nan

Additional benefits

Other plan-specific services and limitations.

Abortion for Which Public Funding is Prohibited

Coverage details pending

nan

Exclusions: nan

Acupuncture

Coverage details pending

nan

Exclusions: nan

Allergy Testing

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

nan

Exclusions: nan

Bariatric Surgery

Coverage details pending

nan

Exclusions: nan

Cosmetic Surgery

Coverage details pending

nan

Exclusions: nan

Eye Glasses for Children

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

Limit: 1.0 Item(s) per Year

Coverage includes benefits specified in the FEDVIP FEP Blue Vision - High Option plan, including low vision benefits.

Exclusions: nan

Gender Affirming Care

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

nan

Exclusions: nan

Habilitation Services

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

Limits may apply to some services; includes benefits for health care services and devices that help a person keep, learn or improve skills and functioning for daily living, including treatment of Autism Spectrum Disorders to children (0 - 21), which at a minimum shall include: (1) Out-Patient Physical Rehabilitation Services including (a) Speech and Language therapy and/or Occupational therapy, 20 visits per year of each service; and (b) Clinical Therapeutic Intervention, which include but are not limited to Applied Behavioral Analysis, 20 hours per week; and (2) Mental/Behavioral Health Outpatient Services to provide consultation, assessment, development and oversight of treatment plans.

Exclusions: nan

Imaging (CT/PET Scans, MRIs)

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

nan

Exclusions: nan

Infertility Treatment

Coverage details pending

Infertility and voluntary family planning services are required benefits under state law for HMO plans only per ORC section 1751.01 (A)(1)(h), and must be provided in accordance with Ohio Department of Insurance Bulletin No. 2009-07.

Exclusions: nan

Long-Term/Custodial Nursing Home Care

Coverage details pending

nan

Exclusions: nan

Private-Duty Nursing

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

Limit: 90.0 Visit(s) per Year

Private Duty Nursing Services are Covered Services only when provided through the Home Care Services benefit; Quantitative Limit has been determined as 90 - 110 visits per year and represents the number of visits to meet the established actuarial equivalent of benchmark plan annual dollar limits. Annual and lifetime dollar limits will no longer apply.

Exclusions: nan

Reconstructive Surgery

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

Benefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance. Benefits include surgery performed to restore symmetry after a mastectomy.

Exclusions: nan

Routine Eye Exam (Adult)

Coverage details pending

nan

Exclusions: nan

Routine Foot Care

Coverage details pending

nan

Exclusions: nan

Treatment for Temporomandibular Joint Disorders

20.00% Coinsurance after deductible
Tier 1 in-network 20.00% Coinsurance after deductible
Out-of-network 40.00% Coinsurance after deductible

Benefits provided for temporomandibular (joint connecting the lower jaw to the temporal bone at the side of the head) and craniomandibular (head and neck muscle) disorders.

Exclusions: nan

Variant attributes

AultCare Gold 1100 Select No Pediatric Dental · Variant 28162OH0060054-01

Plan identifiers & tier

Issuer-provided metadata for this variant.

Business Year

2025

CSR Variation Type

Standard Gold On Exchange Plan

HIOS Product ID

28162OH006

Metal Level

Gold

Plan ID (Standard Component ID with Variant)

28162OH0060054-01

Plan Marketing Name

AultCare Gold 1100 Select No Pediatric Dental

Plan Variant Marketing Name

AultCare Gold 1100 Select No Pediatric Dental

Issuer & service area

Issuer-provided metadata for this variant.

Issuer ID

28162

Issuer Marketplace Marketing Name

AultCare Insurance Company

Market Coverage

Individual

Multiple In Network Tiers

No

National Network

No

Network ID

OHN002

Out of Country Coverage

Yes

Out of Country Coverage Description

Generally, we may pay for limited Emergency Services that are necessary when You are traveling out of the USA, unless you are expressly traveling on business on behalf of Your Employer. We will consider each Claim carefully. We will not pay for Services when You go to another Country to obtain medical care. We do not pay for air transport or medical evacuation. We recommend that You obtain separate medical travel and evacuation insurance if You Plan to travel out of the USA.

Out of Service Area Coverage

Yes

Out of Service Area Coverage Description

Out of Service Area coverage from a network provider would be provided according to the plan benefits. Out of Service Area coverage from a Non-Network provider would be covered at the Non-Network plan benefits and the member would be responsible for any amounts exceeding plan limitations.

Service Area ID

OHS003

State Code

OH

URL for Summary of Benefits & Coverage

Open link

Cost sharing & actuarial values

Issuer-provided metadata for this variant.

AV Calculator Output Number

0.811740230718635

Begin Primary Care Deductible Coinsurance After Number Of Copays

0

Drug EHB Deductible, In Network (Tier 1), Default Coinsurance

50.00%

Inpatient Copayment Maximum Days

0

Medical Drug Deductibles Integrated

No

Medical Drug Maximum Out of Pocket Integrated

Yes

Medical EHB Deductible, In Network (Tier 1), Default Coinsurance

20.00%

SBC Scenario, Having a Baby, Coinsurance

$2,290

SBC Scenario, Having a Baby, Copayment

$10

SBC Scenario, Having a Baby, Deductible

$1,100

SBC Scenario, Having Diabetes, Coinsurance

$950

SBC Scenario, Having Diabetes, Copayment

$320

SBC Scenario, Having Diabetes, Deductible

$1,100

SBC Scenario, Treatment of a Simple Fracture, Coinsurance

$300

SBC Scenario, Treatment of a Simple Fracture, Copayment

$100

SBC Scenario, Treatment of a Simple Fracture, Deductible

$1,100

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group

per group not applicable

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person

per person not applicable

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual

Not Applicable

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group

$13800 per group

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person

$6900 per person

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual

$6,900

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group

$55200 per group

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person

$27600 per person

Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual

$27,600

Enrollment & documents

Issuer-provided metadata for this variant.

Formulary ID

OHF001

Formulary URL

Open link

Plan Brochure

Open link

SBC Scenario, Having a Baby, Limit

$60

SBC Scenario, Having Diabetes, Limit

$20

SBC Scenario, Treatment of a Simple Fracture, Limit

$0

URL for Enrollment Payment

Open link

Additional attributes

Issuer-provided metadata for this variant.

Begin Primary Care Cost-Sharing After Number Of Visits

0

Child-Only Offering

Allows Adult and Child-Only

Composite Rating Offered

No

Drug EHB Deductible, Combined In/Out of Network, Family Per Group

per group not applicable

Drug EHB Deductible, Combined In/Out of Network, Family Per Person

per person not applicable

Drug EHB Deductible, Combined In/Out of Network, Individual

Not Applicable

Drug EHB Deductible, In Network (Tier 1), Family Per Group

$0 per group

Drug EHB Deductible, In Network (Tier 1), Family Per Person

$0 per person

Drug EHB Deductible, In Network (Tier 1), Individual

$0

Drug EHB Deductible, Out of Network, Family Per Group

$0 per group

Drug EHB Deductible, Out of Network, Family Per Person

$0 per person

Drug EHB Deductible, Out of Network, Individual

$0

Dental Only Plan

No

Design Type

Not Applicable

Disease Management Programs Offered

Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

EHB Percent of Total Premium

1.0

First Tier Utilization

100%

Import Date

2024-10-10 20:01:47

Limited Cost Sharing Plan Variation - Estimated Advanced Payment

$0.00

HSA Eligible

No

New/Existing Plan

Existing

Notice Required for Pregnancy

No

Is a Referral Required for Specialist?

No

Medical EHB Deductible, Combined In/Out of Network, Family Per Group

per group not applicable

Medical EHB Deductible, Combined In/Out of Network, Family Per Person

per person not applicable

Medical EHB Deductible, Combined In/Out of Network, Individual

Not Applicable

Medical EHB Deductible, In Network (Tier 1), Family Per Group

$2200 per group

Medical EHB Deductible, In Network (Tier 1), Family Per Person

$1100 per person

Medical EHB Deductible, In Network (Tier 1), Individual

$1,100

Medical EHB Deductible, Out of Network, Family Per Group

$6600 per group

Medical EHB Deductible, Out of Network, Family Per Person

$3300 per person

Medical EHB Deductible, Out of Network, Individual

$3,300

Plan Effective Date

2025-01-01

Plan Expiration Date

2025-12-31

Plan Type

PPO

QHP/Non QHP

Both

Source Name

SERFF

Plan ID

28162OH0060054

Unique Plan Design

No

Wellness Program Offered

No

Copay & coinsurance

Pharmacy cost sharing by tier

Drug tier Pharmacy type Copay amount Copay option Coinsurance rate Coinsurance option Mail order

Questions & answers

Frequently asked questions

How do I choose the right ACA plan in Ohio?

AultCare Gold 1100 Select No Pediatric Dental (28162OH0060054) is a Gold PPO from AultCare Insurance Company in Ohio for the 2025 coverage year.

Compare it against other options with the HealthPorta plan finder to confirm premiums, deductibles, and network access fit your household.

Does AultCare Gold 1100 Select No Pediatric Dental support telehealth or virtual urgent care?

The issuer has not published telehealth details yet. Review the Summary of Benefits and Coverage to confirm if virtual visits are included.

Is AultCare Gold 1100 Select No Pediatric Dental HSA-eligible and does it include dental or vision coverage?

It is not marked as HSA-eligible, so confirm with the issuer before relying on tax-advantaged savings.

Dental coverage is not listed for this plan.

Vision add-ons: Child.

Does AultCare Gold 1100 Select No Pediatric Dental support mail-order prescriptions?

Mail order coverage is not listed for this plan, so confirm with the issuer before relying on home delivery.

Which disease management programs come with AultCare Gold 1100 Select No Pediatric Dental?

The issuer lists disease management resources for: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs.

Is there out-of-country coverage for AultCare Gold 1100 Select No Pediatric Dental?

Yes, limited out-of-country coverage is available. Review the Summary of Benefits for reimbursement steps. Details: Generally, we may pay for limited Emergency Services that are necessary when You are traveling out of the USA, unless you are expressly traveling on business on behalf of Your Employer. We will consider each Claim carefully. We will not pay for Services when You go to another Country to obtain medical care. We do not pay for air transport or medical evacuation. We recommend that You obtain separate medical travel and evacuation insurance if You Plan to travel out of the USA.

Does AultCare Gold 1100 Select No Pediatric Dental cover care outside the service area?

Yes, you have limited out-of-area coverage. See the plan documents for referral and prior authorization rules. Details: Out of Service Area coverage from a network provider would be provided according to the plan benefits. Out of Service Area coverage from a Non-Network provider would be covered at the Non-Network plan benefits and the member would be responsible for any amounts exceeding plan limitations.

How do I enroll in or manage payments for AultCare Gold 1100 Select No Pediatric Dental?

Use the issuer portal https://www.myaultcare.com/paymentListner.aspx to pay premiums or start enrollment, then return to HealthPorta for benefit comparisons.

Disclaimer: Based on the Tue, 02 Dec 2025 06:13 GMT HealthPorta import from CMS issuer filings. Data is best-effort and should be validated with the issuer directly. Sources: CMS.gov and the HealthPorta Healthcare MRF API.
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