Arkansas health plan · 2025

Connected Silver + Vision + Adult Dental · 62141AR0100007

Celtic Insurance Company offers this marketplace health insurance plan (Plan ID 62141AR0100007) 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: Silver Plan type: PPO CSR: 87% AV Level Silver Plan Issuer: Celtic Insurance Company
Telehealth Data pending HSA eligible No Dental Adult Vision Adult/Child
Pay / Manage Plan View issuer site

Issuer actuarial value: 87.85%. Expect to pay roughly 12.15% of covered costs out of pocket, based on issuer reporting.

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

$312 – $1223

Before subsidies

Estimate after subsidies

Deductible

N/A

N/A

See deductible details

Max out-of-pocket

$3,050

$6100 per group

Review MOOP rules

Office visits

Primary care $10.00
Specialist $20.00
HSA Not eligible

Drug tiers

Generic $8.00
Preferred brand $20.00

View formulary tiers

$427 / mo before subsidies

≈ $5127 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.

$1354 / mo before subsidies

≈ $16247 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.
  • This Silver tier qualifies for CSR if household income is ≤250% FPL.

$1640 / mo before subsidies

≈ $19676 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.
  • This Silver tier qualifies for CSR if household income is ≤250% FPL.

$1042 / mo before subsidies

≈ $12504 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

No Charge

Emergency Room Services

$100.00 Copay after deductible

Durable Medical Equipment

$10.00

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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 Arkansas). 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.
  • 87% AV Level Silver 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

No Charge

Emergency Room Services

$100.00 Copay after deductible

Durable Medical Equipment

$10.00

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 62141AR0100007
Coverage year 2025
State Arkansas
Issuer Celtic Insurance Company
Formulary document Download formulary
Marketing materials View marketing kit
Variant ID 62141AR0100007-05
Available variants

Standard Off Exchange Plan · 62141AR0100007-00

Standard On Exchange Plan · 62141AR0100007-01

Open to Indians below 300% FPL · 62141AR0100007-02

Open to Indians above 300% FPL · 62141AR0100007-03

73% AV Silver Plan · 62141AR0100007-04

87% AV Silver Plan · 62141AR0100007-05

94% AV Silver Plan · 62141AR0100007-06
Last plan update Mon, 12 Aug 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 Arkansas 3
PCPs in Arkansas N/A
Telehealth support Data pending
Nationwide providers 3
3 doctors statewide

Provider network(s)

Providers Arkansas All US states
All 3 3
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A

Drug coverage overview

4,670 drugs tracked

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

Tier Covered drugs
GENERIC 2,644
NON-PREFERREDGENERIC-NON-PREFERREDBRAND 2,026
Prior authorization Drugs
Required 1,233
Not Required 3,437
Step therapy Drugs
Required 74
Not Required 4,596
Quantity limits Drugs
Has Limit 2,158
No Limit 2,512

Customer highlights

What stands out for members

  • Issuer: Celtic Insurance Company · Plan ID 62141AR0100007 · 2025 filing.
  • Disease management programs available: Asthma, Diabetes, Heart Disease, Pregnancy.
  • Download the latest formulary directly from the issuer here.
  • Review marketing brochures and SBC PDFs via the issuer marketing repository.
  • Variant 62141AR0100007-05 (87% AV Silver 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
Tier 1 in-network $20.00
Out-of-network 50.00%

Limit: 30.0 Visit(s) per Year

Limited to a combined 30 visit limit per year for outpatient physical therapy, speech therapy, occupational therapy, and chiropractic care. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.

Exclusions: nan

Diabetes Care Management

$20.00
Tier 1 in-network $20.00
Out-of-network 50.00%

nan

Exclusions: nan

Diabetes Education

$20.00
Tier 1 in-network $20.00
Out-of-network 50.00%

Prior authorization may be required - please contact the number listed on your ID card.

Exclusions: nan

Home Health Care Services

$10.00
Tier 1 in-network $10.00
Out-of-network 50.00%

Limit: 50.0 Visit(s) per Year

Prior authorization may be required - please contact the number listed on your ID card.

Exclusions: nan

Laboratory Outpatient and Professional Services

$10.00
Tier 1 in-network $10.00
Out-of-network 50.00%

Prior authorization may be required - please contact the number listed on your ID card.

Exclusions: nan

Mental/Behavioral Health Urgent Care

$10.00
Tier 1 in-network $10.00
Out-of-network 50.00%

nan

Exclusions: nan

Other Practitioner Office Visit (Nurse, Physician Assistant)

$10.00
Tier 1 in-network $10.00
Out-of-network 50.00%

nan

Exclusions: nan

Preventive Care/Screening/Immunization

No Charge
Tier 1 in-network No Charge
Out-of-network 50.00%

Covered in accordance with ACA guidelines.

Exclusions: nan

Primary Care Visit to Treat an Injury or Illness

$10.00
Tier 1 in-network $10.00
Out-of-network 50.00%

nan

Exclusions: nan

Rehabilitative Occupational and Rehabilitative Physical Therapy

$10.00
Tier 1 in-network $10.00
Out-of-network 50.00%

Limit: 30.0 Visit(s) per Year

60 inpatient days/year. Prior authorization may be required - please contact the number listed on your ID card. Limited to a combined 30 visit limit per year for outpatient physical therapy, speech therapy, occupational therapy, and chiropractic care. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.

Exclusions: nan

Rehabilitative Speech Therapy

$10.00
Tier 1 in-network $10.00
Out-of-network 50.00%

Limit: 30.0 Visit(s) per Year

Prior authorization may be required - please contact the number listed on your ID card. Limited to a combined 30 visit limit per year for outpatient physical therapy, speech therapy, occupational therapy, and chiropractic care. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.

Exclusions: nan

Specialist Visit

$20.00
Tier 1 in-network $20.00
Out-of-network 50.00%

nan

Exclusions: nan

Substance Use Disorder Urgent Care

$10.00
Tier 1 in-network $10.00
Out-of-network 50.00%

nan

Exclusions: nan

Urgent Care Centers or Facilities

$10.00
Tier 1 in-network $10.00
Out-of-network 50.00%

nan

Exclusions: nan

X-rays and Diagnostic Imaging

$20.00
Tier 1 in-network $20.00
Out-of-network 50.00%

Prior authorization may be required - please contact the number listed on your ID card.

Exclusions: nan

Hospital & urgent

Emergency room, inpatient stays, ambulance, and surgeries.

Chemotherapy

$100.00 Copay after deductible
Tier 1 in-network $100.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Prior authorization may be required - please contact the number listed on your ID card.

Exclusions: nan

Delivery and All Inpatient Services for Maternity Care

$250.00 Copay after deductible
Tier 1 in-network $250.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Prior authorization may be required - please contact the number listed on your ID card.

Exclusions: nan

Dialysis

$100.00 Copay after deductible
Tier 1 in-network $100.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Prior authorization may be required - please contact the number listed on your ID card.

Exclusions: nan

Durable Medical Equipment

$10.00
Tier 1 in-network $10.00
Out-of-network 50.00%

Prior authorization may be required - please contact the number listed on your ID card.

Exclusions: nan

Emergency Room Services

$100.00 Copay after deductible
Tier 1 in-network $100.00 Copay after deductible
Out-of-network $100.00 Copay after deductible

nan

Exclusions: nan

Emergency Transportation/Ambulance

$250.00 Copay after deductible
Tier 1 in-network $250.00 Copay after deductible
Out-of-network $250.00 Copay after deductible

Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization.

Exclusions: nan

Hospice Services

$35.00 Copay after deductible
Tier 1 in-network $35.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Prior authorization may be required - please contact the number listed on your ID card.

Exclusions: nan

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

$250.00 Copay per Day after deductible
Tier 1 in-network $250.00 Copay per Day after deductible
Out-of-network 50.00% Coinsurance after deductible

Prior authorization may be required - please contact the number listed on your ID card.

Exclusions: nan

Inpatient Physician and Surgical Services

No Charge after deductible
Tier 1 in-network No Charge after deductible
Out-of-network 50.00% Coinsurance after deductible

Prior authorization may be required - please contact the number listed on your ID card.

Exclusions: nan

Mental/Behavioral Health Emergency Room

$50.00 Copay after deductible
Tier 1 in-network $50.00 Copay after deductible
Out-of-network $50.00 Copay after deductible

nan

Exclusions: nan

Mental/Behavioral Health Emergency Transportation/Ambulance

$50.00 Copay after deductible
Tier 1 in-network $50.00 Copay after deductible
Out-of-network $50.00 Copay after deductible

Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization.

Exclusions: nan

Mental/Behavioral Health Inpatient Services

$250.00 Copay per Day after deductible
Tier 1 in-network $250.00 Copay per Day after deductible
Out-of-network 50.00% Coinsurance after deductible

Prior authorization may be required - please contact the number listed on your ID card.

Exclusions: nan

Mental/Behavioral Health Outpatient Other Services

No Charge
Tier 1 in-network No Charge
Out-of-network 50.00%

Prior authorization may be required - please contact the number listed on your ID card. Note: Cost share will be waived for Behavioral Health screening services.

Exclusions: nan

Mental/Behavioral Health Outpatient Services

$10.00
Tier 1 in-network $10.00
Out-of-network 50.00%

Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization. Cost share will be waived for Behavioral Health screening services.

Exclusions: nan

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

$100.00 Copay after deductible
Tier 1 in-network $100.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Prior authorization may be required - please contact the number listed on your ID card.

Exclusions: nan

Outpatient Rehabilitation Services

$10.00
Tier 1 in-network $10.00
Out-of-network 50.00%

Limit: 30.0 Visit(s) per Year

Prior authorization may be required - please contact the number listed on your ID card. Limited to a combined 30 visit limit per year for outpatient physical therapy, speech therapy, occupational therapy, and chiropractic care. Note: Limits do not apply when provided for a mental health/substance use disorder diagnosis.

Exclusions: nan

Outpatient Surgery Physician/Surgical Services

$50.00 Copay after deductible
Tier 1 in-network $50.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Prior authorization may be required - please contact the number listed on your ID card.

Exclusions: nan

Radiation

$100.00 Copay after deductible
Tier 1 in-network $100.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Prior authorization may be required - please contact the number listed on your ID card.

Exclusions: nan

Skilled Nursing Facility

$35.00 Copay per Day after deductible
Tier 1 in-network $35.00 Copay per Day after deductible
Out-of-network 50.00% Coinsurance after deductible

Limit: 60.0 Days per Year

Prior authorization may be required - please contact the number listed on your ID card.

Exclusions: nan

Substance Abuse Disorder Inpatient Services

$250.00 Copay per Day after deductible
Tier 1 in-network $250.00 Copay per Day after deductible
Out-of-network 50.00% Coinsurance after deductible

Prior authorization may be required - please contact the number listed on your ID card.

Exclusions: nan

Substance Abuse Disorder Outpatient Services

$10.00
Tier 1 in-network $10.00
Out-of-network 50.00%

Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage and the policy for more information on an additional outpatient category, Other Outpatient Services, which may apply a different cost share amount and require prior authorization. Note: Office visits do not require prior authorization. Cost share will be waived for Behavioral Health screening services.

Exclusions: nan

Substance Use Disorder Emergency Room

$50.00 Copay after deductible
Tier 1 in-network $50.00 Copay after deductible
Out-of-network $50.00 Copay after deductible

nan

Exclusions: nan

Substance Use Disorder Emergency Transportation/Ambulance

$50.00 Copay after deductible
Tier 1 in-network $50.00 Copay after deductible
Out-of-network $50.00 Copay after deductible

Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization.

Exclusions: nan

Substance Use Disorder Outpatient Other Services

No Charge
Tier 1 in-network No Charge
Out-of-network 50.00%

Prior authorization may be required - please contact the number listed on your ID card. Note: Cost share will be waived for Behavioral Health screening services.

Exclusions: nan

Transplant

$250.00 Copay after deductible
Tier 1 in-network $250.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Prior authorization may be required - please contact the number listed on your ID card.

Exclusions: nan

Mental health & substance use

Behavioral health visits and substance use treatment.

Mental/Behavioral Health ER Physician Fee

$50.00 Copay after deductible
Tier 1 in-network $50.00 Copay after deductible
Out-of-network $50.00 Copay after deductible

nan

Exclusions: nan

Substance Use Disorder ER Physician Fee

$50.00 Copay after deductible
Tier 1 in-network $50.00 Copay after deductible
Out-of-network $50.00 Copay after deductible

nan

Exclusions: nan

Pregnancy & family

Maternity, newborn, pediatric dental and vision extras.

Basic Dental Care - Child

Coverage details pending

nan

Exclusions: nan

Hearing Aids

No Charge
Tier 1 in-network No Charge
Out-of-network 50.00%

Limit: 2.0 Item(s) per 3 Years

Prior authorization may be required - please contact the number listed on your ID card.

Exclusions: nan

Major Dental Care - Child

Coverage details pending

nan

Exclusions: nan

Prenatal and Postnatal Care

$10.00
Tier 1 in-network $10.00
Out-of-network 50.00%

nan

Exclusions: nan

Routine Eye Exam for Children

No Charge
Tier 1 in-network No Charge
Out-of-network No Charge

Limit: 1.0 Exam(s) per Year

Up to $38.50 OON

Exclusions: nan

Well Baby Visits and Care

No Charge
Tier 1 in-network No Charge
Out-of-network 50.00%

nan

Exclusions: nan

Pharmacy & drugs

Generic, brand, specialty, and mail order tiers.

Generic Drugs

$8.00
Tier 1 in-network $8.00
Out-of-network 100.00%

Cost sharing shown applies to Tier 1a-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 1b-Generic Drugs, which may apply a higher cost share. Up to a 30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. Refer to the prescription drug list for more information.

Exclusions: nan

Non-Preferred Brand Drugs

$50.00 Copay after deductible
Tier 1 in-network $50.00 Copay after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Off Label Prescription Drugs

$200.00 Copay after deductible
Tier 1 in-network $200.00 Copay after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Preferred Brand Drugs

$20.00
Tier 1 in-network $20.00
Out-of-network 100.00%

nan

Exclusions: nan

Preventative Drugs

No Charge
Tier 1 in-network No Charge
Out-of-network 100.00%

nan

Exclusions: nan

Specialty Drugs

$200.00 Copay after deductible
Tier 1 in-network $200.00 Copay after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Tier 1b Generic Drugs

$8.00
Tier 1 in-network $8.00
Out-of-network 100.00%

Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90 day Retail Pharmacy. Refer to the prescription drug list for more information.

Exclusions: nan

Wellness & extras

Vision, dental, therapies, prosthetics, weight management.

Accidental Dental

$100.00 Copay after deductible
Tier 1 in-network $100.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Prior authorization may be required - please contact the number listed on your ID card.

Exclusions: nan

Basic Dental Care - Adult

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

Limit: 1000.0 Dollars per Year

$1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults

Exclusions: nan

Dental Anesthesia

$100.00 Copay after deductible
Tier 1 in-network $100.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Dental Check-Up for Children

Coverage details pending

nan

Exclusions: nan

Infusion Therapy

$100.00 Copay after deductible
Tier 1 in-network $100.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Prior authorization may be required - please contact the number listed on your ID card.

Exclusions: nan

Major Dental Care - Adult

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

Limit: 1000.0 Dollars per Year

$1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults

Exclusions: nan

Nutritional Counseling

$20.00
Tier 1 in-network $20.00
Out-of-network 50.00%

nan

Exclusions: nan

Orthodontia - Adult

Coverage details pending

nan

Exclusions: nan

Orthodontia - Child

Coverage details pending

nan

Exclusions: nan

Prosthetic Devices

$10.00
Tier 1 in-network $10.00
Out-of-network 50.00%

Prior authorization may be required - please contact the number listed on your ID card.

Exclusions: nan

Routine Dental Services (Adult)

No Charge
Tier 1 in-network No Charge
Out-of-network No Charge

Limit: 1000.0 Dollars per Year

$1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults

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
Tier 1 in-network $20.00
Out-of-network 50.00%

Prior authorization may be required - please contact the number listed on your ID card.

Exclusions: nan

Applied Behavior Analysis Based Therapies

$100.00 Copay after deductible
Tier 1 in-network $100.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Bariatric Surgery

Coverage details pending

nan

Exclusions: nan

Cardiac Rehabilitation

$10.00
Tier 1 in-network $10.00
Out-of-network 50.00%

Limit: 36.0 Visit(s) per Year

nan

Exclusions: nan

Cochlear Implants

$10.00
Tier 1 in-network $10.00
Out-of-network 50.00%

nan

Exclusions: nan

Cosmetic Surgery

Coverage details pending

nan

Exclusions: nan

Craniofacial Surgery

$250.00 Copay after deductible
Tier 1 in-network $250.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Eye Glasses for Children

No Charge
Tier 1 in-network No Charge
Out-of-network No Charge

Limit: 1.0 Item(s) per Year

OON: Up to $50 for frames, $37.50 for lenses and $91 for contacts in lieu of eyeglasses. See EOC for lens limits.

Exclusions: nan

Gastric Electrical Stimulation

$10.00
Tier 1 in-network $10.00
Out-of-network 50.00%

nan

Exclusions: nan

Gender Affirming Care

$250.00 Copay after deductible
Tier 1 in-network $250.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

nan

Exclusions: nan

Habilitation Services

$10.00
Tier 1 in-network $10.00
Out-of-network 50.00%

Limit: 30.0 Visit(s) per Year

Prior authorization may be required - please contact the number listed on your ID card. Limited to a combined 30 visit limit per year for outpatient habilitation services; limited to 180 visits per year for developmental services.

Exclusions: nan

Imaging (CT/PET Scans, MRIs)

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

Prior authorization may be required - please contact the number listed on your ID card.

Exclusions: nan

Infertility Treatment

$100.00 Copay after deductible
Tier 1 in-network $100.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Prior authorization may be required. Coverage includes testing to diagnose infertility, infertility counseling and planning services; also, in vitro fertilization procedures are covered.

Exclusions: nan

Inherited Metabolic Disorder - PKU

$10.00
Tier 1 in-network $10.00
Out-of-network 50.00%

nan

Exclusions: nan

Long-Term/Custodial Nursing Home Care

Coverage details pending

Long Term Acute Care is a covered benefit. Long Term Nursing Care/Custodial Care is not a covered benefit.

Exclusions: nan

Private-Duty Nursing

Coverage details pending

nan

Exclusions: nan

Reconstructive Surgery

$250.00 Copay after deductible
Tier 1 in-network $250.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

1. Treatment provided for the correction of defects incurred in an Accidental Injury sustained by the Member; 2. Surgery performed on a child for the correction of a cleft palate or cleft lip, removal of a port-wine stain or hemangioma (only on the face), or correction of a congenital abnormality; 3. Treatment provided when it is incidental to disease or for reconstructive surgery following neoplastic (cancer) surgery; 4. In connection with a mastectomy resulting from cancer surgery, services for (a) reconstruction of the breast on which the cancer-related surgery was performed; (b) surgery to reconstruct the other breast to produce a symmetrical appearance; and (c) prostheses and services to correct physical complications for all stages of the mastectomy, including lymphedemas; 5. Reduction mammoplasty, if such reduction mammoplasty meets Coverage Criteria. Prior Authorization may be required - please contact the number listed on your ID card.

Exclusions: nan

Routine Eye Exam (Adult)

No Charge
Tier 1 in-network No Charge
Out-of-network No Charge

Limit: 1.0 Exam(s) per Year

OON exam: Up to $38.50. Benefit also includes 1 pair of eye glasses or contacts per year, covered up to $130 In-Network for frames or $130 In-Network for contacts in lieu of eyeglasses. OON eyewear benefit: covered up to $50 for frames, lenses up to $37.50 and contact lenses up to $91.

Exclusions: nan

Routine Foot Care

$20.00
Tier 1 in-network $20.00
Out-of-network 50.00%

nan

Exclusions: nan

Treatment for Temporomandibular Joint Disorders

$100.00 Copay after deductible
Tier 1 in-network $100.00 Copay after deductible
Out-of-network 50.00% Coinsurance after deductible

Prior authorization may be required - please contact the number listed on your ID card.

Exclusions: nan

Well Child Care

No Charge
Tier 1 in-network No Charge
Out-of-network 50.00%

nan

Exclusions: nan

Variant attributes

Connected Silver + Vision + Adult Dental · Variant 62141AR0100007-05

Plan identifiers & tier

Issuer-provided metadata for this variant.

Business Year

2025

CSR Variation Type

87% AV Level Silver Plan

HIOS Product ID

62141AR010

Metal Level

Silver

Plan ID (Standard Component ID with Variant)

62141AR0100007-05

Plan Marketing Name

Connected Silver + Vision + Adult Dental

Plan Variant Marketing Name

Connected Silver + Vision + Adult Dental

Issuer & service area

Issuer-provided metadata for this variant.

Issuer Actuarial Value

87.85%

Issuer ID

62141

Issuer Marketplace Marketing Name

Ambetter from Arkansas Health & Wellness

Market Coverage

Individual

Multiple In Network Tiers

No

National Network

No

Network ID

ARN001

Out of Country Coverage

No

Out of Service Area Coverage

No

Service Area ID

ARS001

State Code

AR

URL for Summary of Benefits & Coverage

Open link

Cost sharing & actuarial values

Issuer-provided metadata for this variant.

Begin Primary Care Deductible Coinsurance After Number Of Copays

0

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

0.00%

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

0.00%

SBC Scenario, Having a Baby, Coinsurance

$0

SBC Scenario, Having a Baby, Copayment

$200

SBC Scenario, Having a Baby, Deductible

$2,800

SBC Scenario, Having Diabetes, Coinsurance

$0

SBC Scenario, Having Diabetes, Copayment

$800

SBC Scenario, Having Diabetes, Deductible

$0

SBC Scenario, Treatment of a Simple Fracture, Coinsurance

$0

SBC Scenario, Treatment of a Simple Fracture, Copayment

$200

SBC Scenario, Treatment of a Simple Fracture, Deductible

$1,700

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

$29100 per group

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

$14550 per person

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

$14,550

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

$6100 per group

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

$3050 per person

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

$3,050

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

$23000 per group

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

$11500 per person

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

$11,500

Enrollment & documents

Issuer-provided metadata for this variant.

Formulary ID

ARF001

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

$200 per group

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

$100 per person

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

$100

Drug EHB Deductible, Out of Network, Family Per Group

per group not applicable

Drug EHB Deductible, Out of Network, Family Per Person

per person not applicable

Drug EHB Deductible, Out of Network, Individual

Not Applicable

Dental Only Plan

No

Design Type

Not Applicable

Disease Management Programs Offered

Asthma, Diabetes, Heart Disease, Pregnancy

EHB Percent of Total Premium

0.965649944220338

First Tier Utilization

100%

Import Date

2024-08-12 20:01:40

Limited Cost Sharing Plan Variation - Estimated Advanced Payment

$0.00

HSA Eligible

No

New/Existing Plan

Existing

Notice Required for Pregnancy

Yes

Is a Referral Required for Specialist?

No

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

$22200 per group

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

$11100 per person

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

$11,100

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

$5900 per group

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

$2950 per person

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

$2,950

Medical EHB Deductible, Out of Network, Family Per Group

$16300 per group

Medical EHB Deductible, Out of Network, Family Per Person

$8150 per person

Medical EHB Deductible, Out of Network, Individual

$8,150

Plan Effective Date

2025-01-01

Plan Type

PPO

QHP/Non QHP

Both

Source Name

SERFF

Plan ID

62141AR0100007

Unique Plan Design

Yes

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 Arkansas?

Connected Silver + Vision + Adult Dental (62141AR0100007) is a Silver PPO from Celtic Insurance Company in Arkansas 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 Connected Silver + Vision + Adult 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 Connected Silver + Vision + Adult 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 add-ons: Adult.

Vision add-ons: Adult, Child.

Does Connected Silver + Vision + Adult 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 Connected Silver + Vision + Adult Dental?

The issuer lists disease management resources for: Asthma, Diabetes, Heart Disease, Pregnancy.

Is there out-of-country coverage for Connected Silver + Vision + Adult Dental?

No, out-of-country services are not covered for this plan.

Does Connected Silver + Vision + Adult Dental cover care outside the service area?

No, the issuer indicates out-of-service-area care is not covered except for emergencies.

How do I enroll in or manage payments for Connected Silver + Vision + Adult Dental?

Use the issuer portal https://ambetter.arhealthwellness.com/payments 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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