The Schedule of Benefits is a summary of services that may be covered under the plan.

Benefits listed are subject to

all provisions and limitations as outlined in the Evidence of Coverage (EOC). Please reference the EOC for details
regarding the benefits listed below. The member is responsible for deductible, copayment or coinsurance applied to
eligible service expenses. For services that require prior authorization, network providers must obtain
authorization from us prior to providing a service or supply to a member. You should confirm with your provider
that they have received prior authorization for a covered service prior to your treatment. An overview of Preventive
Services covered with no cost share can be found within your EOC.
Pursuant to the Federal No Surprises Act, you are only required to pay the in-network cost sharing for non-network
emergency care, including air ambulance services; for certain ancillary services provided by non-network providers
at in-network facilities; and for covered services by a non-network provider at an in-network facility when you do
not provide informed consent. Charges you incur for services from a non-network provider that fall in the scenarios
listed above will accumulate towards your in-network deductible and/or maximum out-of-pocket amount. Please
refer to your EOC for further information.

Clear Silver + Vision + Adult Dental-94% AV Level Silver Plan

Benefit Insured Responsibility (per person)
In-Network Providers Out-of-Network Providers

Annual Deductible per Calendar $550 Individual $1,650 Individual

Year $1,100 Family $3,300 Family
Prescription Drug Deductible per Integrated with medical deductible Not Applicable Individual
Calendar Year Individual Not Applicable Family
Integrated with medical deductible
Family
Coinsurance after deductible for 0% Coinsurance 30% Coinsurance
Eligible Expenses (unless
otherwise noted)
Out-of-Pocket Maximum per $550 Individual Not applicable Individual
Calendar Year $1,100 Family Not applicable Family
Provider Office Services
Primary Care Office Visit No charge after deductible 30% Coinsurance after deductible
Specialist Office Visit No charge after deductible 30% Coinsurance after deductible
Preventive Care (including No charge 30% Coinsurance
screenings, immunizations and well-
baby visits)
Covered in accordance with ACA
guidelines.
Diagnostic Test* (x-ray) No charge after deductible 30% Coinsurance after deductible
Diagnostic Test* Lab-work/Other No charge after deductible 30% Coinsurance after deductible
(e.g., bloodwork, EKG, Stress Test)
Imaging Test* (CT/PET scans, MRI) No charge after deductible 30% Coinsurance after deductible
Prescription Drugs
Tier 1a: Preferred Generic No charge after deductible Not covered
Tier 1b: Generic* No charge after deductible Not covered
Tier 2: Preferred Brand* No charge after deductible Not covered
Tier 3: Non-Preferred Brand and Non- No charge after deductible Not covered
Preferred Generic *
Tier 4: Specialty* No charge after deductible Not covered
Mail Order * (90-day supply) 3 Times Retail Cost Sharing Not covered
Insulin medications are covered with a maximum cost share of $30 per 30-day supply.
Outpatient Services
Outpatient Facility* No charge after deductible 30% Coinsurance after deductible
Outpatient Surgery No charge after deductible 30% Coinsurance after deductible
Physician/Surgical Services*
Emergency and Urgent Care Services
62505OK0130015-06-2024
*Prior authorization may be required. Please contact Member Services at the number listed on your member identification card to determine if
prior authorization is needed.
Note: Cost share for covered services is based on place of service. Telehealth and Virtual Care Services received by a provider other than your
designated telehealth provider will incur the same cost share as an in-person visit.
 Emergency Room No charge after deductible No charge after deductible
ER Physician Fee No charge after deductible No charge after deductible
Emergency No charge after deductible No charge after deductible
Transportation/Ambulance (Water,
Air (fixed wing, rotary wing), or
Ground) Note: Prior authorization is
not required for emergency transport,
however, all non-emergent transport
requires prior authorization.
Urgent Care No charge after deductible 30% Coinsurance
Virtual 24/7 Care No charge 30% Coinsurance after deductible
Inpatient Hospital Services
Inpatient Hospital Facility* No charge after deductible 30% Coinsurance after deductible
Inpatient Hospital Physician and No charge after deductible 30% Coinsurance after deductible
Surgical Services*
Behavioral Health Treatment: Mental Health and Substance Use Disorder Services
Behavioral Health Outpatient Office Visit: No charge after 30% Coinsurance after deductible
Services* (PCP and other deductible;
practitioner office visits do not Other Outpatient Services: No charge
require prior authorization.) after deductible
Behavioral Health Inpatient Services* No charge after deductible 30% Coinsurance after deductible
Behavioral Health Emergency Room No charge after deductible No charge after deductible
Behavioral Health ER Physician Fee No charge after deductible No charge after deductible
Behavioral Health Emergency No charge after deductible No charge after deductible
Transportation/Ambulance (Water,
Air (fixed wing, rotary wing), or
Ground) Note: Prior authorization is
not required for emergency transport,
however, all non-emergent transport
requires prior authorization.
Behavioral Health Urgent Care No charge after deductible 30% Coinsurance
Behavioral Health Laboratory No charge after deductible 30% Coinsurance after deductible
Services*
Behavioral Health Habilitation No charge after deductible 30% Coinsurance after deductible
Outpatient Services* (Including
speech, occupational and physical
therapy)
Behavioral Health Habilitation No charge after deductible 30% Coinsurance after deductible
Inpatient Services* (Including speech,
occupational and physical therapy)
Maternity and Newborn Care
Prenatal and Postnatal Care No charge after deductible 30% Coinsurance after deductible
Delivery and Inpatient Services* No charge after deductible 30% Coinsurance after deductible

Other Covered Services

Home Health Care Services* No charge after deductible 30% Coinsurance after deductible
Limited to 30 visits per year.
Rehabilitation Outpatient Services* No charge after deductible 30% Coinsurance after deductible
(Including speech, occupational and
physical therapy)
Limited to a combined 25 visit limit
for occupational, speech and physical
therapy. Note: Limits do not apply
when provided for a mental
health/substance use disorder
diagnosis.
62505OK0130015-06-2024
*Prior authorization may be required. Please contact Member Services at the number listed on your member identification card to determine if
prior authorization is needed.
Note: Cost share for covered services is based on place of service. Telehealth and Virtual Care Services received by a provider other than your
designated telehealth provider will incur the same cost share as an in-person visit.
 Rehabilitation Inpatient Services* No charge after deductible 30% Coinsurance after deductible
(Including speech, occupational and
physical therapy)
Limited to 30 days per year. Note:
Limits do not apply when provided
for a mental health/substance use
disorder diagnosis.
Cardiac Rehabilitation* No charge after deductible 30% Coinsurance after deductible

Habilitation Inpatient Services* No charge after deductible 30% Coinsurance after deductible
(Including speech, occupational and
physical therapy) Limited to 30 days
per year. Note: Limits do not apply
when provided for a mental
health/substance use disorder
diagnosis.
Habilitation Outpatient Services* No charge after deductible 30% Coinsurance after deductible
(Including speech, occupational and
physical therapy)
Limited to a combined 25 visit limit
for occupational, speech and physical
therapy. Note: Limits do not apply
when provided for a mental
health/substance use disorder
diagnosis.
Skilled Nursing Facility* No charge after deductible 30% Coinsurance after deductible
Limited to 30 days per year.
Durable Medical Equipment* No charge after deductible 30% Coinsurance after deductible
Hospice Services* No charge after deductible 30% Coinsurance after deductible

Private Duty Nursing* No charge after deductible 30% Coinsurance after deductible
Limited to 85 visits per year.
Accidental Dental* No charge after deductible 30% Coinsurance after deductible

Chiropractic Care* No charge after deductible 30% Coinsurance after deductible

Transplant Benefit* No charge after deductible 30% Coinsurance after deductible

Limited to $10,000 for transportation
& lodging per transplant; $30,000 for
donor search per transplant.
Allergy Testing* No charge after deductible 30% Coinsurance after deductible
Hearing Aids* No charge after deductible 30% Coinsurance after deductible
Limited to 1 per ear every 4 years.
Diabetes Care Management No charge after deductible 30% Coinsurance after deductible

Vision Services – Pediatric (Children under the age of 19)

Exam
Routine eye exam (& contact lens 100% Covered Covered up to $38.50
fitting)
Limited to 1 visit per year.
Standard Frame
Eyeglasses (frames) 100% Covered Covered up to $50
Limited to 1 item per year.
Lenses (per pair)
Prescription lenses (including 100% Covered Covered up to $37.50
additional lens options)
62505OK0130015-06-2024
*Prior authorization may be required. Please contact Member Services at the number listed on your member identification card to determine if
prior authorization is needed.
Note: Cost share for covered services is based on place of service. Telehealth and Virtual Care Services received by a provider other than your
designated telehealth provider will incur the same cost share as an in-person visit.
 Contact lenses (in lieu of glasses) 100% Covered Covered up to $91
1 item per year
Vision Services – Adult (19 years of age and older)
Exam
Routine eye exam (& contact lens 100% Covered Covered up to $38.50
fitting)
Limited to 1 visit per year.
Frame
Eyeglasses (frames) Covered up to $130 Covered up to $50
Limited to 1 item per year.
Lenses (per pair)
Prescription lenses (including 100% Covered Covered up to $37.50
additional lens options)
Contact lenses (in lieu of glasses) Covered up to $130 Covered up to $91
Dental – Adult (19 years of age and older)

Dental Benefit Maximum (all services $1,000 per covered person per $1,000 per covered person per calendar
apply toward benefit maximum) calendar year year
Preventative and Diagnostic (Routine Dental Services) – Class 1
Routine cleanings – 2 per 12 months No charge, subject to Annual No charge, subject to Annual Maximum
Oral exams – 2 per 12 months Maximum
X-rays – bite-wing, full mouth and
panoramic film
Topical fluoride application – 2 per 12
months
Basic Services – Class 2
Minor restorative – metal or resin- 50% coinsurance, subject to Annual 50% coinsurance, subject to Annual
based fillings Maximum Maximum
Endodontics – root canals
Periodontics – scaling, root planing
and periodontal maintenance
Simple extractions
Removable Prosthodontics – relines,
rebase, adjustment and repairs
Major Services – Class 3
Crown and bridges 50% coinsurance, subject to Annual 50% coinsurance, subject to Annual
Dentures Maximum Maximum
Impactions, complex extractions and
surgical services

Value-add Programs
Ambetter members can earn reward dollars by participating in the My Health Pays™ rewards program. The My Health Pays
program rewards you for being more active in your health. Visit AmbetterofOklahoma.com to learn more about the program
and ways to earn and spend rewards. You can also call Member Services at 1-833-492-0679 (TTY 711). Rewards programs
may vary by the plan you are enrolled in.

62505OK0130015-06-2024
*Prior authorization may be required. Please contact Member Services at the number listed on your member identification card to determine if
prior authorization is needed.
Note: Cost share for covered services is based on place of service. Telehealth and Virtual Care Services received by a provider other than your
designated telehealth provider will incur the same cost share as an in-person visit.
 If you, or someone you are helping, have questions about Ambetter of Oklahoma, and are not proficient in English, you have the
right to get help and information in your language at no cost and in a timely manner. If you, or someone you are helping, have an
English: auditory and/or visual condition that impedes communication, you have the right to receive auxiliary aids and services at no cost
and in a timely manner. To receive translation or auxiliary services, please contact Member Services at 1-833-492-0679
(TTY 711).

Si usted, o alguien a quien está ayudando, tiene preguntas acerca de Ambetter of Oklahoma y no domina el inglés, tiene derecho
a obtener ayuda e información en su idioma sin costo alguno y de manera oportuna. Si usted, o alguien a quien está ayudando,
Spanish: tiene un impedimento auditivo o visual que le dificulta la comunicación, tiene derecho a recibir ayuda y servicios auxiliares sin
costo alguno y de manera oportuna. Para recibir servicios auxiliares o de traducción, comuníquese con Servicios para Miembros
al 1-833-492-0679 (TTY 711).

Nếu quý vị hoặc người mà quý vị đang giúp đỡ có câu hỏi về Ambetter of Oklahoma và không thành thạo tiếng Anh, quý vị có
quyền được trợ giúp và nhận thông tin bằng ngôn ngữ của mình miễn phí và kịp thời. Nếu quý vị hoặc người mà quý vị đang giúp
Vietnamese: đỡ mắc bệnh về thính giác và/hoặc thị giác gây cản trở giao tiếp, quý vị có quyền được nhận các hỗ trợ và dịch vụ phụ trợ miễn
phí và kịp thời. Để nhận dịch vụ thông dịch hoặc dịch vụ phụ trợ, vui lòng liên hệ bộ phận Dịch Vụ Thành Viên theo số
1-833-492-0679 (TTY 711).

如果您，或是您正在協助的對象，有關於 Ambetter of Oklahoma 方面的問題，且不精通英語，您有權利免費並及時以您的母語獲

Chinese: 幫助和訊息。如果您，或您正在協助的對象有聽力和/或視力上的問題，阻礙了溝通，您有權利免費並及時獲得輔助支援與服務。若
要取得翻譯或輔助服務，請聯絡會員服務部，電話是 1-833-492-0679 (TTY 711)。

귀하 또는 귀하의 도움을 받는 분이 Ambetter of Oklahoma에 대한 질문이 있는 경우 영어에 능숙하지 않으시면 해당 언어로

시의적절하게 무료 지원과 정보를 받을 권리가 있습니다. 귀하 또는 귀하의 도움을 받는 분이 청각 및/또는 시각적으로 의사소통에
Korean:
장애가 있는 경우 시의적절하게 무료 보조 도구 및 서비스를 받을 권리가 있습니다. 번역 또는 보조 서비스를 받으시려면
1-833-492-0679(TTY 711)번으로 가입자 서비스부에 연락해주십시오.

Falls Sie oder jemand, dem Sie helfen, Fragen zu Ambetter of Oklahoma hat und nicht Englisch spricht, haben Sie das Recht,
kostenlos und zeitnah Hilfe und Informationen in Ihrer Sprache zu erhalten. Falls Sie oder jemand, dem Sie helfen, eine
German: Hör- und/oder Sehbeeinträchtigung hat, die die Kommunikation beeinflusst, haben Sie das Recht, kostenlos und zeitnah
zusätzliche Hilfe und Dienstleistungen zu erhalten. Um eine Übersetzung oder zusätzliche Dienstleistungen zu erhalten, wenden
Sie sich an den Kundendienst unter 1-833-492-0679 (TTY 711).

‫ فلدیك الحق في الحصول على المساعدة والمعلومات بلغتك من دون‬،‫ ولم تكن بارعًا باللغة اإلنكلیزیة‬،Ambetter of Oklahoma ‫إذا كان لدیك أو لدى شخص تساعده أسئلة حول‬
Arabic: ‫ فلدیك الحق في تلقي مساعدات وخدمات إضافیة من دون أي تكلفة‬،‫أو بصریة تعیق التواصل‬/‫ إذا كنت أنت أو أي شخص تساعده تعاني من حالة سمعیة و‬.‫أي تكلفة وفي الوقت المناسب‬
.1-833-492-0679 (TTY 711) ‫ یرجى االتصال بـ خدمات األعضاء على‬،‫ لتلقي خدمات الترجمة أو خدمات إضافیة‬.‫وفي الوقت المناسب‬

အကယ်၍ သင် သမဟု

ု ို့ တ် သင်ကူညီနေသူတစ်ဦးသည် Ambetter of Oklahoma အန ကြောင်းနှင ို့် ပတ်သက်၍ နမးခွေး် မ ြေား နမးလုပပီး အင်္ဂလပ်လု
ကျွမ်းက င်စွြော မန ပြောနင
ု ပ
် ါက၊ သငို့တ
် ွင ် အကူအညီနင
ှ ို့် အခ က်အလက်မ ြေားကု သငို့ဘ
် ြောသြောစကြေား ြငို့် အခန ကးနငွ နပးစရြောမလဘ
ု ဲ
အခ ေ်နင
ှ တ
ို့် စ်န ပးညီ ရယူပုငခ
် ွငရ
ို့် ှသည်။ အကယ်၍ သင် သမဟု
ု ို့ တ် သင်ကူညီနေသူတစ်ဦးသည် ဆက်သွယ်နရးကု အဟေအ
် ို့ တြေား ြစ်နစနသြော
Burmese:
အ ကြေားအြောရု နှင/ို့် သမဟု
ု ို့ တ် အ မင်အြောရု နင
ှ ို့် သက်ဆုငန
် သြော အန ခအနေတစ်ခရ
ု ှပါက၊ သငို့တ
် ွင ် အရေ်အကူအညီမ ြေားနှင ို့် ဝေ်နဆြောင်မှုမ ြေားကု
အခန ကးနငွ နပးစရြောမလဘ
ု ဲ အခ ေ်နင
ှ တ
ို့် စ်န ပးညီ ရယူပုငခ
် ွငရ
ို့် သည်
ှ ။ ဘြောသြော ပေ် သမဟု
ု ို့ တ် အရေ်ဝေ်နဆြောင်မှုမ ြေားကု လက်ခရယူရေ်
1-833-492-0679 (TTY 711) ရှ အြွဲွဲ့ဝင် ဝေ်နဆြောင်မှုမ ြေား ကု ဆက်သွယ်ပါ။

Yog tias koj, los sis ib tug neeg twg uas koj tab tom muab kev pab, muaj cov lus nug hais txog Ambetter of Oklahoma, thiab tsis
paub lus Askiv zoo heev, koj muaj cai tau txais kev pab thiab tej ntaub ntawv qhia paub ua koj hom lus yam tsis tau them dab tsi
li thiab kom tau raws sij hawm. Yog tias koj, los sis ib tug neeg twg uas koj tab tom pab, muaj tsos mob txog kev hnov lus
Hmong: thiab/los sis kev pom kev uas cuam tshuam txog kev sib txuas lus, koj muaj cai kom tau txais cov kev pab thiab cov kev pab
cuam ntxiv yam tsis tau them dab tsi li thiab kom tau raws sij hawm. Txhawm rau kom tau txais cov kev pab cuam txhais ntawv
los sis kev pab ntxiv, thov tiv tauj Member Services (Cov Chaw Muab Kev Pab Cuam Tswv Cuab) tau ntawm 1-833-492-0679
(TTY 711).

62505OK0130015-06-2024
*Prior authorization may be required. Please contact Member Services at the number listed on your member identification card to determine if
prior authorization is needed.
Note: Cost share for covered services is based on place of service. Telehealth and Virtual Care Services received by a provider other than your
designated telehealth provider will incur the same cost share as an in-person visit.
 Kung ikaw, o ang iyong tinutulungan, ay may mga katanungan tungkol sa Ambetter of Oklahoma, at hindi ka mahusay sa Ingles, may
karapatan ka na makakuha ng tulong at impormasyon sa iyong wika nang walang gastos at sa maagap na paraan. Kung ikaw, o ang
iyong tinutulungan, ay may kondisyon sa pandinig at/o paningin na nakakaapekto sa komunikasyon, may karapatan kang
Tagalog:
makatanggap ng mga karagdagang tulong at serbisyo nang walang gastos at sa maagap na paraan. Para makatanggap ng mga
serbisyo sa pagsasalin o mga karagdagang serbisyo, mangyaring makipag-ugnayan sa Mga Serbisyo para sa Miyembro sa
1-833-492-0679 (TTY 711).

Si vous-même ou une personne que vous aidez avez des questions à propos d'Ambetter of Oklahoma et que vous ne maîtrisez
pas l'anglais, vous pouvez bénéficier gratuitement et en temps utile d'aide et d'informations dans votre langue. Si vous-même ou
French: une personne que vous aidez souffrez d'un trouble auditif ou visuel qui entrave la communication, vous pouvez bénéficier
gratuitement et en temps utile d'aides et de services auxiliaires. Pour profiter de services de traduction ou de services auxiliaires,
veuillez contacter Services aux membres au 1-833-492-0679 (TTY 711).

ຖ້ າຫາກທ່ ານ ຫຼື ຜ້ ໃດຜ້ ໜ່ ງທ່ ທ່ ານກາລັງໃຫ້ ການຊ່ ວຍເຫຼື ອ, ມຄາຖາມກ່ ຽວກັບ Ambetter of Oklahoma, ແລະ ບ່ ຊ່ ຽວຊານພາສາອັງກິດ,
ທ່ ານມສິດໄດ້ ຮັບການຊ່ ວຍເຫຼື ອ ແລະ ຂ້ ມນທ່ ເປັນພາສາຂອງທ່ ານໂດຍບ່ ມຄ່ າໃຊ້ ຈ່າຍ ແລະ ທັນເວລາ. ຖ້ າຫາກທ່ ານ ຫຼື ຜ້ ໃດຜ້ ໜ່ ງທ່ ທ່ ານກາລັງໃຫ້ ການຊ່ວຍເຫຼື ອ,
Laotian: ມສະພາບທາງການໄດ້ ຍິນ ແລະ/ຫຼື ການເບ່ິ ງເຫັນທ່ ຂັດຂວາງການສ່ຼື ສານ, ທ່ ານມສິດໄດ້ ຮັບການຊ່ ວຍເຫຼື ອ ແລະ ການບລິການເສມໂດຍບ່ ມຄ່ າໃຊ້ ຈ່າຍ ແລະ
ທັນເວລາ. ເພຼື່ອໃຫ້ ໄດ້ ຮັບການບລິການແປພາສາ ຫຼື ບລິການເສມ, ກະລຸ ນາຕິດຕ່ ຫາ Member Services (ການບລິການສະມາຊິກ) ໄດ້ ທ່ 1-833-492-0679
(TTY 711).

หากคุณหรือคนทีค ่ ณุ กาลังให ้ความช่วยเหลือมีคาถามเกีย ่ วกับ Ambetter of Oklahoma และไม่ชานาญในการใช ้ภาษาอังกฤษ

ิ ธิท
คุณมีสท ์ จี่ ะขอรับความช่วยเหลือและข ้อมูลในภาษาของคุณโดยไม่เสียค่าใช ้จ่ายอย่างทันท่วงที
Thai: หากคุณหรือคนทีค ่ ณ ่ สาร
ุ กาลังให ้ความช่วยเหลือมีภาวะด ้านการฟั งและ/หรือการมองเห็นทีเ่ ป็ นอุปสรรคต่อการสือ
คุณมีสทิ ธิท์ จ ี่ ะขอรับความช่วยเหลือและบริการเสริมโดยไม่เสียค่าใช ้จ่ายอย่างทันท่วงที หากต ้องการบริการด ้านการแปลหรือบริการเสริม
โปรดติดต่อ บริการสาหรับสมาชิก ทีห ่ มายเลข 1-833-492-0679 (TTY 711)

‫ تو آپ کو اپنی زبان میں‬،‫ اور وه انگریزی میں ماہر نہیں ہیں‬،‫ کے بارے میں سواالت کرنا چاہتے ہیں‬Ambetter of Oklahoma ‫ یا جس کی آپ مدد کررہے ہیں وه‬،‫اگر آپ‬
‫یا بصارت میں کوئی پریشانی درپیش ہو جس‬/‫ انہیں سماعت اور‬،‫ یا جس کی آپ مدد کر رہے ہیں‬،‫بال معاوضہ اور بروقت مدد اور معلومات حاصل کرنے کا حق ہے۔ اگر آپ‬
Urdu:
‫ براه کرم‬،‫ تو آپ کو مفت اور بر وقت معاون امداد اور خدمات حاصل کرنے کا حق ہے۔ ترجمہ یا معاون خدمات حاصل کرنے کے لیے‬،‫سے مواصلت میں رک اوٹ پیدا ہوتی ہے‬
‫ پر ممبر سروسز سے رابطہ کریں۔‬1-833-492-0679 (TTY 711)

ᎬᏗ ᏂᎨᎢ ᎢᎯᏍᏉ, ᎠᎴ ᎩᎶᎢ ᎯᎠ ᎦᎵᏔᏅᏔᏅ ᎠᏍᏕᎵᎭ, ᎤᏙᏓᏆᎠ ᎤᏚᏓᎳ ᎤᎵᏗᏨ ᎠᏓᏅᏖᎭ_ᏕᎪᎠ, ᎠᎴ ᎦᎶᏔᏅᎥᏍᎦ ᎨᏍᏗ ᎠᏏᎾᎭ Ambetter of
Oklahoma, ᎢᎯᏍᏉ ᎤᏙᏓᏆᎠ ᏃᎴ ᎠᏘᏍᎩ ᏰᎵᏉ ᎠᎩᎠ ᎠᏍᏕᎵᎭ ᎠᎴ ᎦᏁᏫᏗᎭ ᎬᏗ ᎢᎯᏍᏉ ᎢᎬᏁᎢᏍᏗ ᎰᏫᏂᏣ ᎭᏗ ᏧᎬᏩᎶᏗ ᎠᎴ ᎬᏗ a ᎢᏳᏩᏂᎸᎯ
Cherokee: ᎠᎬᏱᏗᏣ. ᎬᏗ ᏂᎨᎢ ᎢᎯᏍᏉ, ᎠᎴ ᎩᎶᎢ ᎯᎠ ᎦᎵᏔᏅᏔᏅ ᎠᏍᏕᎵᎭ, ᎤᏙᏓᏆᎠ ᏃᎴ ᎠᎦᏛᎲᏍᎦ ᎠᎴ/ᎠᎴ ᏗᏥᎶᏍᏓᏅᎯ ᎱᏳᎩ ᏍᎩ ᎠᏔᏲᎯᎭ ᎤᏗᎴᎬᎢ,
ᎢᎯᏍᏉ ᎤᏙᏓᏆᎠ ᏃᎴ ᎠᏘᏍᎩ ᏰᎵᏉ ᏓᏓᏂᎸᎦ ᎠᏎᎯᎭ ᎠᏍᏕᎵᎭ ᎠᎴ ᎤᏙᎳᏂ ᎰᏫᏂᏣ ᎭᏗ ᏧᎬᏩᎶᏗ ᎠᎴ ᎬᏗ a ᎢᏳᏩᏂᎸᎯ ᎠᎬᏱᏗᏣ. ᏰᎵᏉ ᏓᏓᏂᎸᎦ ᎠᏁᏍᏗᎭ
ᎠᎴ ᎠᏎᎯᎭ ᎤᏙᎳᏂ, ᎠᏔᏲᎯᎭ ᎠᏒᏂᎭ ᏴᏫ ᎤᏙᎳᏂ ᎰᏫᏂᏣ 1-833-492-0679 (TTY 711).

‫ حق دارید کمک و اطالعات را به زبان خودتان به رایگان‬،‫ و انگلیسی نمی دانید‬،‫ دارید‬Ambetter of Oklahoma ‫ سؤالی درباره‬،‫اگر شما یا فردی که دارید به او کمک میکنید‬
Persian: ‫ حق دارید کمکها و خدمات امدادی را‬،‫ اگر شما یا فردی که دارید به او کمک میکنید مشکالت شنوایی یا بینایی دارد که برقراری ارتباط را سخت میکند‬.‫و به موقع دریافت کنید‬
.‫ تماس بگیرید‬1-833-492-0679 (TTY 711) ‫ برای دریافت کمکها و خدمات امدادی لطفا ً با خدمات اعضا به شماره‬.‫به زبان خودتان به رایگان و به موقع دریافت کنید‬

AMB23-OK-C-00057

62505OK0130015-06-2024
*Prior authorization may be required. Please contact Member Services at the number listed on your member identification card to determine if
prior authorization is needed.
Note: Cost share for covered services is based on place of service. Telehealth and Virtual Care Services received by a provider other than your
designated telehealth provider will incur the same cost share as an in-person visit.
 Statement of Non-Discrimination

Ambetter of Oklahoma is underwritten by Celtic Insurance Company, which is a Qualified Health Plan issuer in
the Oklahoma Health Insurance Marketplace. Celtic Insurance Company complies with applicable Federal civil
rights laws and does not discriminate on the basis of race, color, national origin (including limited English
proficiency and primary language), age, disability, or sex (including pregnancy, sexual orientation, gender
identity, or sex characteristics). This is a solicitation for insurance. © 2023 Celtic Insurance Company. All rights
reserved. AmbetterofOklahoma.com

If you, or someone you are helping, have questions about Ambetter of Oklahoma, and are not proficient in
English, you have the right to get help and information in your language at no cost and in a timely manner. If
you, or someone you are helping, have an auditory and/or visual condition that impedes communication, you
have the right to receive auxiliary aids and services at no cost and in a timely manner. To receive translation or
auxiliary services, please contact Member Services at 1-833-492-0679 (TTY 711). If you believe that Celtic
Insurance Company has failed to provide these services or discriminated in another way on the basis of race,
color, national origin (including limited English proficiency and primary language), age, disability, or sex
(including pregnancy, sexual orientation, gender identity, or sex characteristics), please contact Member
Services at 1-833-492-0679 (TTY 711). You may also submit a grievance by phone to 1-833-492-0679 (TTY
711). For information on filing a discrimination complaint directly with the U.S. Department of Health and
Human Services, Office of Civil Rights, please visit https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf.

AMB23-OK-C-00056
Ambetter of Oklahoma is underwritten by Celtic Insurance Company, which is a Qualified Health Plan issuer in
the Oklahoma Health Insurance Marketplace. This is a solicitation for insurance. © 2023 Celtic Insurance
Company. All rights reserved.

62505OK0130015-06-2024
*Prior authorization may be required. Please contact Member Services at the number listed on your member identification card to determine if
prior authorization is needed.
Note: Cost share for covered services is based on place of service. Telehealth and Virtual Care Services received by a provider other than your
designated telehealth provider will incur the same cost share as an in-person visit.
 Declaración de No Discriminación

Ambetter de Oklahoma está suscrito por Celtic Insurance Company, que es un emisor del Plan de salud
calificado en el Mercado de seguros de salud de Oklahoma. Celtic Insurance Company cumple con las leyes
de derechos civiles Federales aplicables y no discrimina por motivos de raza, color de piel, nacionalidad de
origen (incluidos un nivel de inglés limitado y la lengua materna), edad, discapacidad o sexo (incluidos el
embarazo, la orientación sexual, la identidad de género o las características sexuales). Esta es publicidad de
seguro. © 2023 Celtic Insurance Company. Todos los derechos reservados. AmbetterofOklahoma.com

Si usted, o alguien a quien está ayudando, tiene preguntas acerca de Ambetter de Oklahoma y no domina el
inglés, tiene derecho a obtener ayuda e información en su idioma sin costo alguno y de manera oportuna. Si
usted, o alguien a quien está ayudando, tiene un impedimento auditivo o visual que le dificulta la comunicación,
tiene derecho a recibir ayuda y servicios auxiliares sin costo alguno y de manera oportuna. Para recibir servicios
auxiliares o de traducción, comuníquese con Servicios para Miembros al 1-833-492-0679 (TTY 711). Si
considera que Celtic Insurance Company no le proporcionó estos servicios o lo discriminó de otra manera por
motivos de raza, color de piel, nacionalidad de origen (incluidos un nivel de inglés limitado y la lengua materna),
edad, discapacidad o sexo (incluidos el embarazo, la orientación sexual, la identidad de género o las
características sexuales), comuníquese con Servicios para Miembros al 1-833-492-0679 (TTY 711). También
puede presentar una queja por teléfono al 1-833-492-0679 (TTY 711). Para obtener información sobre cómo
presentar una queja por discriminación directamente ante la Oficina de Derechos Civiles del Departamento de
Salud y Servicios Humanos de EE. UU., visite https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf.

AMB23-OK-C-00056
Ambetter de Oklahoma está suscrito por Celtic Insurance Company, que es un emisor del Plan de salud
calificado en el Mercado de seguros de salud de Oklahoma. Esta es publicidad de seguro. © 2023 Celtic
Insurance Company. Todos los derechos reservados.

62505OK0130015-06-2024
*Prior authorization may be required. Please contact Member Services at the number listed on your member identification card to determine if
prior authorization is needed.
Note: Cost share for covered services is based on place of service. Telehealth and Virtual Care Services received by a provider other than your
designated telehealth provider will incur the same cost share as an in-person visit.