Louisiana health plan · 2025

Elite Silver + Vision + Adult Dental · 90787LA0020012

Ambetter Health of Louisiana offers this marketplace health insurance plan (Plan ID 90787LA0020012) 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: EPO CSR: Standard Silver Off Exchange Plan Issuer: Ambetter Health of Louisiana
Telehealth Data pending HSA eligible No Dental Adult Vision Adult/Child
Pay / Manage Plan View issuer site

Issuer actuarial value: 70.35%. Expect to pay roughly 29.65% 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

$307 – $1450

Before subsidies

Estimate after subsidies

Deductible

N/A

N/A

See deductible details

Max out-of-pocket

$8,200

$16400 per group

Review MOOP rules

Office visits

Primary care $50.00
Specialist $90.00
HSA Not eligible

Drug tiers

Generic $3.00
Preferred brand 45.00% Coinsurance after deductible

View formulary tiers

$432 / mo before subsidies

≈ $5188 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.

$1551 / mo before subsidies

≈ $18611 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.

$1836 / mo before subsidies

≈ $22027 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.

$1235 / mo before subsidies

≈ $14824 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

50.00%

Durable Medical Equipment

50.00%

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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 Louisiana). 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 Silver Off 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

No Charge

Emergency Room Services

50.00%

Durable Medical Equipment

50.00%

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 90787LA0020012
Coverage year 2025
State Louisiana
Issuer Ambetter Health of Louisiana
Formulary document Download formulary
Marketing materials View marketing kit
Variant ID 90787LA0020012-00
Available variants

Standard Off Exchange Plan · 90787LA0020012-00

Standard On Exchange Plan · 90787LA0020012-01

Open to Indians below 300% FPL · 90787LA0020012-02

Open to Indians above 300% FPL · 90787LA0020012-03

73% AV Silver Plan · 90787LA0020012-04

87% AV Silver Plan · 90787LA0020012-05

94% AV Silver Plan · 90787LA0020012-06
Last plan update Tue, 13 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 Louisiana 14
PCPs in Louisiana 3
Telehealth support Data pending
Nationwide providers 74
14 doctors statewide 3 PCPs

Provider network(s)

Providers Louisiana All US states
All 14 74
PCP 3 14
Allergy N/A N/A
OB/GYN N/A N/A
Dentists 1 4

Drug coverage overview

4,675 drugs tracked

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

Tier Covered drugs
GENERIC 2,654
NON-PREFERREDGENERIC-NON-PREFERREDBRAND 2,021
Prior authorization Drugs
Required 1,228
Not Required 3,447
Step therapy Drugs
Required 73
Not Required 4,602
Quantity limits Drugs
Has Limit 2,110
No Limit 2,565

Customer highlights

What stands out for members

  • Issuer: Ambetter Health of Louisiana · Plan ID 90787LA0020012 · 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 90787LA0020012-00 (Standard Off 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

$90.00
Tier 1 in-network $90.00
Out-of-network 100.00%

nan

Exclusions: nan

Diabetes Education

$90.00
Tier 1 in-network $90.00
Out-of-network 100.00%

nan

Exclusions: nan

Home Health Care Services

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

nan

Exclusions: nan

Laboratory Outpatient and Professional Services

$50.00
Tier 1 in-network $50.00
Out-of-network 100.00%

nan

Exclusions: nan

Mental/Behavioral Health Urgent Care

$50.00
Tier 1 in-network $50.00
Out-of-network 100.00%

nan

Exclusions: nan

Other Practitioner Office Visit (Nurse, Physician Assistant)

$50.00
Tier 1 in-network $50.00
Out-of-network 100.00%

nan

Exclusions: nan

Preventive Care/Screening/Immunization

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

Covered in accordance with ACA guidelines.

Exclusions: nan

Primary Care Visit to Treat an Injury or Illness

$50.00
Tier 1 in-network $50.00
Out-of-network 100.00%

Unlimited Virtual 24/7 Care Visits received from Ambetters designated telehealth provider covered at No Charge, except for HSAs.

Exclusions: nan

Rehabilitative Occupational and Rehabilitative Physical Therapy

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

nan

Exclusions: nan

Rehabilitative Speech Therapy

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

nan

Exclusions: nan

Specialist Visit

$90.00
Tier 1 in-network $90.00
Out-of-network 100.00%

nan

Exclusions: nan

Substance Use Disorder Urgent Care

$50.00
Tier 1 in-network $50.00
Out-of-network 100.00%

nan

Exclusions: nan

Urgent Care Centers or Facilities

$60.00
Tier 1 in-network $60.00
Out-of-network 100.00%

nan

Exclusions: nan

X-rays and Diagnostic Imaging

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

nan

Exclusions: nan

Hospital & urgent

Emergency room, inpatient stays, ambulance, and surgeries.

Chemotherapy

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

nan

Exclusions: nan

Delivery and All Inpatient Services for Maternity Care

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

nan

Exclusions: nan

Dialysis

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

nan

Exclusions: nan

Durable Medical Equipment

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

nan

Exclusions: nan

Emergency Room Services

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

nan

Exclusions: nan

Emergency Transportation/Ambulance

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

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

Exclusions: nan

Hospice Services

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

Respite Care is not a covered benefit.

Exclusions: nan

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

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

nan

Exclusions: nan

Inpatient Physician and Surgical Services

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

nan

Exclusions: nan

Mental/Behavioral Health Emergency Room

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

nan

Exclusions: nan

Mental/Behavioral Health Emergency Transportation/Ambulance

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

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

Exclusions: nan

Mental/Behavioral Health Inpatient Services

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

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

Exclusions: nan

Mental/Behavioral Health Outpatient Other Services

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

nan

Exclusions: nan

Mental/Behavioral Health Outpatient Services

$50.00
Tier 1 in-network $50.00
Out-of-network 100.00%

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.

Exclusions: nan

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

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

nan

Exclusions: nan

Outpatient Rehabilitation Services

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

nan

Exclusions: nan

Outpatient Surgery Physician/Surgical Services

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

nan

Exclusions: nan

Radiation

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

nan

Exclusions: nan

Skilled Nursing Facility

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

nan

Exclusions: nan

Substance Abuse Disorder Inpatient Services

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

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

Exclusions: nan

Substance Abuse Disorder Outpatient Services

$50.00
Tier 1 in-network $50.00
Out-of-network 100.00%

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.

Exclusions: nan

Substance Use Disorder Emergency Room

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

nan

Exclusions: nan

Substance Use Disorder Emergency Transportation/Ambulance

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

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

Exclusions: nan

Substance Use Disorder Outpatient Other Services

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

nan

Exclusions: nan

Transplant

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

Limited to $10,000 for transportation & lodging per transplant; $30,000 for donor search per transplant.

Exclusions: nan

Mental health & substance use

Behavioral health visits and substance use treatment.

Mental/Behavioral Health ER Physician Fee

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

nan

Exclusions: nan

Substance Use Disorder ER Physician Fee

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

nan

Exclusions: nan

Pregnancy & family

Maternity, newborn, pediatric dental and vision extras.

Basic Dental Care - Child

Coverage details pending

nan

Exclusions: nan

Hearing Aids

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

Limit: 2.0 Item(s) per 3 Years

Cochlear Implants and Bone Anchored Hearing Aids are a covered benefit. One hearing aid per ear every 3 years.

Exclusions: nan

Major Dental Care - Child

Coverage details pending

nan

Exclusions: nan

Prenatal and Postnatal Care

$50.00
Tier 1 in-network $50.00
Out-of-network 100.00%

nan

Exclusions: nan

Routine Eye Exam for Children

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

Limit: 1.0 Exam(s) per Year

nan

Exclusions: nan

Well Baby Visits and Care

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

Covered in accordance with ACA Guidelines.

Exclusions: nan

Pharmacy & drugs

Generic, brand, specialty, and mail order tiers.

Generic Drugs

$3.00
Tier 1 in-network $3.00
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

45.00% Coinsurance after deductible
Tier 1 in-network 45.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Preferred Brand Drugs

45.00% Coinsurance after deductible
Tier 1 in-network 45.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Specialty Drugs

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

nan

Exclusions: nan

Tier 1b Generic Drugs

$30.00
Tier 1 in-network $30.00
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

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

nan

Exclusions: nan

Basic Dental Care - Adult

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

Limit: 1000.0 Dollars per Year

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

Exclusions: nan

Dental Check-Up for Children

Coverage details pending

nan

Exclusions: nan

Infusion Therapy

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

nan

Exclusions: nan

Major Dental Care - Adult

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

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

$90.00
Tier 1 in-network $90.00
Out-of-network 100.00%

nan

Exclusions: nan

Orthodontia - Adult

Coverage details pending

nan

Exclusions: nan

Orthodontia - Child

Coverage details pending

nan

Exclusions: nan

Prosthetic Devices

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

nan

Exclusions: nan

Routine Dental Services (Adult)

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

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

$90.00
Tier 1 in-network $90.00
Out-of-network 100.00%

nan

Exclusions: nan

Bariatric Surgery

Coverage details pending

nan

Exclusions: nan

Cosmetic Surgery

Coverage details pending

See Reconstructive Surgery.

Exclusions: nan

Eye Glasses for Children

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

Limit: 1.0 Item(s) per Year

nan

Exclusions: nan

Gender Affirming Care

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

nan

Exclusions: nan

Habilitation Services

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

nan

Exclusions: nan

Imaging (CT/PET Scans, MRIs)

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

nan

Exclusions: nan

Infertility Treatment

Coverage details pending

Limited to services for diagnostic tests to find the cause of infertility. Services to treat the underlying medical conditions that cause infertility are covered (e.g., endometriosis, obstructed fallopian tubes, and hormone deficiency).

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

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

Available on home and outpatient basis only (inpatient excluded).

Exclusions: nan

Reconstructive Surgery

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

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.

Exclusions: nan

Routine Eye Exam (Adult)

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

Limit: 1.0 Exam(s) per Year

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 eye glasses.

Exclusions: nan

Routine Foot Care

$90.00
Tier 1 in-network $90.00
Out-of-network 100.00%

nan

Exclusions: nan

Treatment for Temporomandibular Joint Disorders

50.00%
Tier 1 in-network 50.00%
Out-of-network 100.00%

nan

Exclusions: nan

Variant attributes

Elite Silver + Vision + Adult Dental · Variant 90787LA0020012-00

Plan identifiers & tier

Issuer-provided metadata for this variant.

Business Year

2025

CSR Variation Type

Standard Silver Off Exchange Plan

HIOS Product ID

90787LA002

Metal Level

Silver

Plan ID (Standard Component ID with Variant)

90787LA0020012-00

Plan Marketing Name

Elite Silver + Vision + Adult Dental

Plan Variant Marketing Name

Elite Silver + Vision + Adult Dental

Issuer & service area

Issuer-provided metadata for this variant.

Issuer Actuarial Value

70.35%

Issuer ID

90787

Issuer Marketplace Marketing Name

Ambetter from Louisiana Healthcare Connections

Market Coverage

Individual

Multiple In Network Tiers

No

National Network

No

Network ID

LAN001

Out of Country Coverage

No

Out of Service Area Coverage

No

Service Area ID

LAS001

State Code

LA

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

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

50.00%

SBC Scenario, Having a Baby, Coinsurance

$4,400

SBC Scenario, Having a Baby, Copayment

$600

SBC Scenario, Having a Baby, Deductible

$0

SBC Scenario, Having Diabetes, Coinsurance

$1,100

SBC Scenario, Having Diabetes, Copayment

$800

SBC Scenario, Having Diabetes, Deductible

$1,500

SBC Scenario, Treatment of a Simple Fracture, Coinsurance

$1,200

SBC Scenario, Treatment of a Simple Fracture, Copayment

$300

SBC Scenario, Treatment of a Simple Fracture, Deductible

$0

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

$16400 per group

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

$8200 per person

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

$8,200

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

per group not applicable

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

per person not applicable

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

Not Applicable

Enrollment & documents

Issuer-provided metadata for this variant.

Formulary ID

LAF009

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

$3000 per group

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

$1500 per person

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

$1,500

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

0.9608

First Tier Utilization

100%

Import Date

2024-08-13 01:01:24

Limited Cost Sharing Plan Variation - Estimated Advanced Payment

$0.00

HSA Eligible

No

New/Existing Plan

New

Notice Required for Pregnancy

Yes

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

$0 per group

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

$0 per person

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

$0

Medical EHB Deductible, Out of Network, Family Per Group

per group not applicable

Medical EHB Deductible, Out of Network, Family Per Person

per person not applicable

Medical EHB Deductible, Out of Network, Individual

Not Applicable

Plan Effective Date

2025-01-01

Plan Type

EPO

QHP/Non QHP

Both

Source Name

HIOS

Plan ID

90787LA0020012

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 Louisiana?

Elite Silver + Vision + Adult Dental (90787LA0020012) is a Silver EPO from Ambetter Health of Louisiana in Louisiana 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 Elite 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 Elite 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 Elite 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 Elite Silver + Vision + Adult Dental?

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

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

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

Does Elite 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.

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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