Ambetter Silver Plans

 

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If you’re looking for a balance on your monthly premium payments and your out-of-pocket costs, Silver plans provide just that. And, Silver plans are the only plans with additional out-of-pocket payment reductions (cost sharing reductions)! This helps lower the costs of your copays, deductibles and coinsurance.

Plan Name Balanced Care 1 (2017) – Standard Balanced Care 1 (2017) – 73% AV Balanced Care 1 (2017) – 87% AV
Balanced Care 1 (2017) – 94% AV
Medical Deductible(Ind/Fam) $5,500/$11,000 $3,500/$7,000 $450/$900 $0/$0
Prescription Drug Deductible(Ind/Fam) Integrated with medical ded. Integrated with medical ded. Integrated with medical ded.
Integrated with medical ded.
Metal Level Silver Silver Silver Silver
Out-of-pocket Maximum(Ind/Fam) $6,500/$13,000 $5,450/$10,900 $2,250/$4,500 $700/$1,400
Annual Well Visit/ Preventive Care No charge No charge No charge No charge
PCP Office Visit $30 $20 $1 $1
Specialist Office Visit $60 $30 $10 $10
Imaging(CT/PET Scans, MRIs) 20% after ded. 20% after ded. 20% after ded. 20% after ded.
X-rays & Diagnostic Imaging 20% after ded. 20% after ded. 20% after ded. 20% after ded.
Urgent Care $100 $75 $50 $50
Emergency Room* 20% after ded. 20% after ded. 20% after ded. 20% after ded.
Emergency Transportation* 20% after ded. 20% after ded. 20% after ded. 20% after ded.
Inpatient Facility Fee 20% after ded. 20% after ded. 20% after ded. 20% after ded.
Inpatient Hospital Physician & Surgical Services 20% after ded. 20% after ded. 20% after ded. 20% after ded.
Outpatient Facility Fee 20% after ded. 20% after ded. 20% after ded. 20% after ded.
Outpatient Surgery Physician/Surgical Services 20% after ded. 20% after ded. 20% after ded. 20% after ded.
Labs & Diagnostics 20% after ded. 20% after ded. 20% after ded. 20% after ded.
Mental/Behavioral Health & Substance Use Disorder Outpatient Services $30 $20 $1 $1
Rehabilitation Outpatient Services(Includes Speech, Occupational, Physical Therapy) 20% after ded. 20% after ded. 20% after ded. 20% after ded.
Skilled Nursing Facility 20% after ded. 20% after ded. 20% after ded. 20% after ded.
Pediatric Vision- Routine Eye Exam(1 visit per year) 100% Covered 100% Covered 100% Covered 100% Covered
Pediatric Vision- Eyeglasses(frames, 1 per year) 100% Covered 100% Covered 100% Covered 100% Covered
Pedicatric Vision- Lenses(per pair) 100% Covered 100% Covered 100% Covered 100% Covered
Plan Name Balanced Care 2 (2017) – Standard Balanced Care 2 (2017) – 73% AV Balanced Care 2 (2017) – 87% AV
Balanced Care 2 (2017) – 94% AV
Medical Deductible(Ind/Fam) $6,500/$13,000 $5,000/$10,000 $1,750/$3,500 $575/$1,150
Prescription Drug Deductible(Ind/Fam) Integrated with medical ded. Integrated with medical ded. Integrated with medical ded.
Integrated with medical ded.
Metal Level Silver Silver Silver Silver
Out-of-pocket Maximum(Ind/Fam) $6,500/$13,000 $5,000/$10,000 $1,750/$3,500 $575/$1,150
Annual Well Visit/ Preventive Care No charge No charge No charge No charge
PCP Office Visit $30 $25 $1 $1
Specialist Office Visit $60 $50 $5 $5
Imaging(CT/PET Scans, MRIs) No charge after ded. No charge after ded. No charge after ded.
No charge after ded.
X-rays & Diagnostic Imaging No charge after ded. No charge after ded. No charge after ded.
No charge after ded.
Urgent Care $100 $75 $50 $50
Emergency Room* No charge after ded. No charge after ded. No charge after ded.
No charge after ded.
Emergency Transportation* No charge after ded. No charge after ded. No charge after ded.
No charge after ded.
Inpatient Facility Fee No charge after ded. No charge after ded. No charge after ded.
No charge after ded.
Inpatient Hospital Physician & Surgical Services No charge after ded. No charge after ded. No charge after ded.
No charge after ded.
Outpatient Facility Fee No charge after ded. No charge after ded. No charge after ded.
No charge after ded.
Outpatient Surgery Physician/Surgical Services No charge after ded. No charge after ded. No charge after ded.
No charge after ded.
Labs & Diagnostics No charge after ded. No charge after ded. No charge after ded.
No charge after ded.
Mental/Behavioral Health & Substance Use Disorder Outpatient Services $30 $25 $1 $1
Rehabilitation Outpatient Services(Includes Speech, Occupational, Physical Therapy) No charge after ded. No charge after ded. No charge after ded.
No charge after ded.
Skilled Nursing Facility No charge after ded. No charge after ded. No charge after ded.
No charge after ded.
Pediatric Vision- Routine Eye Exam(1 visit per year) 100% Covered 100% Covered 100% Covered 100% Covered
Pediatric Vision- Eyeglasses(frames, 1 per year) 100% Covered 100% Covered 100% Covered 100% Covered
Pedicatric Vision- Lenses(per pair) 100% Covered 100% Covered 100% Covered 100% Covered
Pharmacy*
(Generic / Preferred / Non-preferred / Specialty)
$15 / $50 / No charge after ded. / No charge after ded. $15 / $50 / No charge after ded. / No charge after ded. $1 / $25 / No charge after ded. / No charge after ded.
$1 / $25 / No charge after ded. / No charge after ded.
Plan Name Balanced Care 4 (2017) – Standard Balanced Care 4 (2017) – 73% AV Balanced Care 4 (2017) – 87% AV
Balanced Care 4 (2017) – 94% AV
Medical Deductible(Ind/Fam) $7,050/$14,100 $5,250/$10,500 $2,000/$4,000 $600/$1,200
Prescription Drug Deductible(Ind/Fam) Integrated with medical ded. Integrated with medical ded. Integrated with medical ded.
Integrated with medical ded.
Metal Level Silver Silver Silver Silver
Out-of-pocket Maximum(Ind/Fam) $7,050/$14,100 $5,250/$10,500 $2,000/$4,000 $600/$1,200
Annual Well Visit/ Preventive Care No charge No charge No charge No charge
PCP Office Visit $30 $15 No charge No charge
Specialist Office Visit $60 $40 $5 $5
Imaging(CT/PET Scans, MRIs) No charge after ded. No charge after ded. No charge after ded.
No charge after ded.
X-rays & Diagnostic Imaging No charge after ded. No charge after ded. No charge after ded.
No charge after ded.
Urgent Care $100 $75 $50 $50
Emergency Room* No charge after ded. No charge after ded. No charge after ded.
No charge after ded.
Emergency Transportation* No charge after ded. No charge after ded. No charge after ded.
No charge after ded.
Inpatient Facility Fee No charge after ded. No charge after ded. No charge after ded.
No charge after ded.
Inpatient Hospital Physician & Surgical Services No charge after ded. No charge after ded. No charge after ded.
No charge after ded.
Outpatient Facility Fee No charge after ded. No charge after ded. No charge after ded.
No charge after ded.
Outpatient Surgery Physician/Surgical Services No charge after ded. No charge after ded. No charge after ded.
No charge after ded.
Labs & Diagnostics No charge after ded. No charge after ded. No charge after ded.
No charge after ded.
Mental/Behavioral Health & Substance Use Disorder Outpatient Services $30 $15 No charge No charge
Rehabilitation Outpatient Services(Includes Speech, Occupational, Physical Therapy) No charge after ded. No charge after ded. No charge after ded.
No charge after ded.
Skilled Nursing Facility No charge after ded. No charge after ded. No charge after ded.
No charge after ded.
Pediatric Vision- Routine Eye Exam(1 visit per year) 100% Covered 100% Covered 100% Covered 100% Covered
Pediatric Vision- Eyeglasses(frames, 1 per year) 100% Covered 100% Covered 100% Covered 100% Covered
Pedicatric Vision- Lenses(per pair) 100% Covered 100% Covered 100% Covered 100% Covered
Pharmacy*
(Generic / Preferred / Non-preferred / Specialty)
$15 / $50 / No charge after ded. / No charge after ded. $15 / $50 / No charge after ded. / No charge after ded. No charge / $25 / No charge after ded. / No charge after ded.
No charge / $25 / No charge after ded. / No charge after ded.
Plan Name Balanced Care 10 (2017) – Standard Balanced Care 10 (2017) – 73% AV Balanced Care 10 (2017) – 87% AV
Balanced Care 10 (2017) – 94% AV
Medical Deductible(Ind/Fam) $4,500/$9,000 $4,000/$8,000 $1,000/$2,000 $250/$500
Prescription Drug Deductible(Ind/Fam) Integrated with medical ded. Integrated with medical ded. Integrated with medical ded.
Integrated with medical ded.
Metal Level Silver Silver Silver Silver
Out-of-pocket Maximum(Ind/Fam) $6,500/$13,000 $5,500/$11,000 $1,750/$3,500 $550/$1,100
Annual Well Visit/ Preventive Care No charge No charge No charge No charge
PCP Office Visit $20 $10 $1 $1
Specialist Office Visit $40 $20 $5 $5
Imaging(CT/PET Scans, MRIs) 20% after ded. 20% after ded. 20% after ded. 20% after ded.
X-rays & Diagnostic Imaging 20% after ded. 20% after ded. 20% after ded. 20% after ded.
Urgent Care $100 $75 $50 $50
Emergency Room* 20% after ded. 20% after ded. 20% after ded. 20% after ded.
Emergency Transportation* 20% after ded. 20% after ded. 20% after ded. 20% after ded.
Inpatient Facility Fee 20% after ded. 20% after ded. 20% after ded. 20% after ded.
Inpatient Hospital Physician & Surgical Services 20% after ded. 20% after ded. 20% after ded. 20% after ded.
Outpatient Facility Fee 20% after ded. 20% after ded. 20% after ded. 20% after ded.
Outpatient Surgery Physician/Surgical Services 20% after ded. 20% after ded. 20% after ded. 20% after ded.
Labs & Diagnostics 20% after ded. 20% after ded. 20% after ded. 20% after ded.
Mental/Behavioral Health & Substance Use Disorder Outpatient Services $20 $10 $1 $1
Rehabilitation Outpatient Services(Includes Speech, Occupational, Physical Therapy) 20% after ded. 20% after ded. 20% after ded. 20% after ded.
Skilled Nursing Facility 20% after ded. 20% after ded. 20% after ded. 20% after ded.
Pediatric Vision- Routine Eye Exam(1 visit per year) 100% Covered 100% Covered 100% Covered 100% Covered
Pediatric Vision- Eyeglasses(frames, 1 per year) 100% Covered 100% Covered 100% Covered 100% Covered
Pedicatric Vision- Lenses(per pair) 100% Covered 100% Covered 100% Covered 100% Covered
Pharmacy*
(Generic / Preferred / Non-preferred / Specialty)
$10 / $50 / 20% after ded. / 20% after ded. $5 / $50 / 20% after ded. / 20% after ded. $1 / $25 / 20% after ded. / 20% after ded.
$1 / $25 / 20% after ded. / 20% after ded.
Plan Name Balanced Care 12 (2017) – Standard Balanced Care 12 (2017) – 73% AV Balanced Care 12 (2017) – 87% AV
Balanced Care 12 (2017) – 94% AV
Medical Deductible(Ind/Fam) $3,500/$7,000 $3,000/$6,000 $700/$1,400 $250/$500
Prescription Drug Deductible(Ind/Fam) Integrated with medical ded. Integrated with medical ded. Integrated with medical ded.
Integrated with medical ded.
Metal Level Silver Silver Silver Silver
Out-of-pocket Maximum(Ind/Fam) $7,150/$14,300 $5,700/$11,400 $2,000/$4,000 $1,250/$2,500
Annual Well Visit/ Preventive Care No charge No charge No charge No charge
PCP Office Visit $30 $30 $10 $5
Specialist Office Visit $65 $65 $25 $15
Imaging(CT/PET Scans, MRIs) 20% after ded. 20% after ded. 20% after ded. 5% after ded.
X-rays & Diagnostic Imaging 20% after ded. 20% after ded. 20% after ded. 5% after ded.
Urgent Care $75 $75 $40 $25
Emergency Room* $400 after ded. $300 after ded. $150 after ded. $100 after ded.
Emergency Transportation* 20% after ded. 20% after ded. 20% after ded. 5% after ded.
Inpatient Facility Fee 20% after ded. 20% after ded. 20% after ded. 5% after ded.
Inpatient Hospital Physician & Surgical Services 20% after ded. 20% after ded. 20% after ded. 5% after ded.
Outpatient Facility Fee 20% after ded. 20% after ded. 20% after ded. 5% after ded.
Outpatient Surgery Physician/Surgical Services 20% after ded. 20% after ded. 20% after ded. 5% after ded.
Labs & Diagnostics 20% after ded. 20% after ded. 20% after ded. 5% after ded.
Mental/Behavioral Health & Substance Use Disorder Outpatient Services $30 $30 $10 $5
Rehabilitation Outpatient Services(Includes Speech, Occupational, Physical Therapy) 20% after ded. 20% after ded. 20% after ded. 5% after ded.
Skilled Nursing Facility 20% after ded. 20% after ded. 20% after ded. 5% after ded.
Pediatric Vision- Routine Eye Exam(1 visit per year) 100% Covered 100% Covered 100% Covered 100% Covered
Pediatric Vision- Eyeglasses(frames, 1 per year) 100% Covered 100% Covered 100% Covered 100% Covered
Pedicatric Vision- Lenses(per pair) 100% Covered 100% Covered 100% Covered 100% Covered
Pharmacy*
(Generic / Preferred / Non-preferred / Specialty)
$15 / $50 / $100 / 40% $10 / $50 / $100 / 40% $5 / $25 / $50 / 30%
$3 / $5 / $10 / 25%

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