Ambetter Bronze Plans
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- Ambetter Essential Care 1 (+Vision & Adult Dental)
- Ambetter Essential Care 1 + Vision (Zero Cost Share)
| Medical Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. | $6,800 |
| Medical CoinsuranceWhat % you pay after your deductible has been met and before your out of pocket max | 0% Coinsurance |
| Prescription Drug Annual Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. | Integrated with medical deductible |
| Prescription Drug CoinsuranceWhat % you pay after your deductible has been met and before your out of pocket max | Integrated with medical coinsurance |
| Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services | $6,800 |
| Emergency Services | |
| Emergency Room Services | No charge after deductible |
| Emergency Transportation/Ambulance (Air or Ground) | No charge after deductible |
| Urgent Care | No charge after deductible |
| Provider Services | |
| Annual Well Visit/Screening/Immunization/Well Baby | No charge |
| Primary Care Visit to treat an injury or illness and Maternity | No charge after deductible |
| Specialist Visit (e.g. Cardiology, Podiatry, Chiropractic Care) | No charge after deductible |
| Imaging (CT/PET Scans, MRIs) | No charge after deductible |
| X-rays & Diagnostic imaging | No charge after deductible |
| Inpatient & Outpatient Services | |
| Inpatient Facility Fee (Includes Mental Health, Substanc Use and Maternity) | No charge after deductible |
| Inpatient Hospital Physician & Surgical Services | No charge after deductible |
| Outpatient Facility Fee (e.g. Ambulatory Surgery Center) | No charge after deductible |
| Outpatient Surgery Physician/Surgical Services | No charge after deductible |
| Laboratory Outpatient & Professional Services | No charge after deductible |
| Other Medical Services | |
| Mental/Behavioral Health & Substance Use Disorder Outpatient Services | No charge after deductible |
| Rehabilitation Outpatient Services (includes Speech, Occupational and Physical Therapy) | No charge after deductible |
| Skilled Nursing Facility | No charge after deductible |
| Pediatric Vision | |
| Routine Eye Exam | 100% covered |
| Eyeglasses | 100% covered |
| Lenses | 100% covered |
| Prescription Drugs | |
| Generics | $20 copay |
| Preferred Brand Drugs | No charge after deductible |
| Non-preferred Brand Drugs | No charge after deductible |
| Specialty Drugs | No charge after deductible |
| Pediatric Vision | |
| Exams and Eyewear: Routine Eye Exam | 100% Covered |
| Eyeglasses | 100% Covered |
| Lenses (per pair): Single | 100% Covered |
| Bifocal | 100% Covered |
| Trifocal | 100% Covered |
| Lenticular | 100% Covered |
| Contact Lenses: Contact lenses (in lieu of glasses) | 100% Covered |
| Contact lens fitting | 100% Covered |
| Specialty lens fitting | 100% Covered |
| Adult Vision | |
| Exams and Eyewear: Routine Eye Exam | 100% Covered |
| Eyeglasses | Covered up to $130 |
| Lenses(per pair): Single | 100% Covered |
| Bifocal | 100% Covered |
| Trifocal | 100% Covered |
| Lenticular | 100% Covered |
| Contact Lenses (in lieu of glasses) | Covered up to $130 |
| Contact lens fitting | 100% Covered |
| Specialty lens fitting | Covered up to $50 |
| Adult Dental (Ages 19 years of age and older, does not include Pediatric Dental Coverage) | |
| Annual Maximum Dental Benefit | $1,000 per covered person per calendar year |
| Routine Dental | |
| Routine Oral Exam | No charge, subject to Annual Maximum |
| Routine Cleaning | No charge, subject to Annual Maximum |
| Bite-wing X-ray | No charge, subject to Annual Maximum |
| Full Mouth X-ray | No charge, subject to Annual Maximum |
| Panoramic Film | No charge, subject to Annual Maximum |
| Topical Fluoride Application | No charge, subject to Annual Maximum |
| Palliative Treatment for relief of pain | No charge, subject to Annual Maximum |
| Basic Dental | |
| Basic Services: Silver Fillings | 50% coinsurance, subject to Annual Maximum |
| tooth Colored Fillings | 50% coinsurance, subject to Annual Maximum |
| Endodontics: Therapeutic Pulpotomy on permanent teeth | 50% coinsurance, subject to Annual Maximum |
| Periodontics: Scaling & Root Planning | 50% coinsurance, subject to Annual Maximum |
| Periodontal Maintenance | 50% coinsurance, subject to Annual Maximum |
| Oral Surgery: Simple Extractions | 50% coinsurance, subject to Annual Maximum |
| Surgical Extractions | 50% coinsurance, subject to Annual Maximum |
| Removal of Impacted Teeth | 50% coinsurance, subject to Annual Maximum |
| Alveoloplasty | 50% coinsurance, subject to Annual Maximum |
| Prosthodontics: Relines | 50% coinsurance, subject to Annual Maximum |
| Rebase | 50% coinsurance, subject to Annual Maximum |
| Adjustments | 50% coinsurance, subject to Annual Maximum |
| Repairs | 50% coinsurance, subject to Annual Maximum |
| Medical Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. | $0 |
| Medical CoinsuranceWhat % you pay after your deductible has been met and before your out of pocket max | 0% Coinsurance |
| Prescription Drug Annual Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. | Integrated with medical deductible |
| Prescription Drug CoinsuranceWhat % you pay after your deductible has been met and before your out of pocket max | Integrated with medical coinsurance |
| Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services | $0 |
| Emergency Services | |
| Emergency Room Services | No charge |
| Emergency Transportation/Ambulance (Air or Ground) | No charge |
| Urgent Care | No charge |
| Provider Services | |
| Annual Well Visit/Screening/Immunization/Well Baby | No charge |
| Primary Care Visit to treat an injury or illness and Maternity | No charge |
| Specialist Visit (e.g. Cardiology, Podiatry, Chiropractic Care) | No charge |
| Imaging (CT/PET Scans, MRIs) | No charge |
| X-rays & Diagnostic imaging | No charge |
| Inpatient & Outpatient Services | |
| Inpatient Facility Fee (Includes Mental Health, Substanc Use and Maternity) | No charge |
| Inpatient Hospital Physician & Surgical Services | No charge |
| Outpatient Facility Fee (e.g. Ambulatory Surgery Center) | No charge |
| Outpatient Surgery Physician/Surgical Services | No charge |
| Laboratory Outpatient & Professional Services | No charge |
| Other Medical Services | |
| Mental/Behavioral Health & Substance Use Disorder Outpatient Services | No charge |
| Rehabilitation Outpatient Services (includes Speech, Occupational and Physical Therapy) | No charge |
| Skilled Nursing Facility | No charge |
| Pediatric Vision | |
| Routine Eye Exam | 100% covered |
| Eyeglasses | 100% covered |
| Lenses | 100% covered |
| Prescription Drugs | |
| Generics | No charge |
| Preferred Brand Drugs | No charge |
| Non-preferred Brand Drugs | No charge |
| Specialty Drugs | No charge |
| Pediatric Vision | |
| Exams and Eyewear: Routine Eye Exam | 100% Covered |
| Eyeglasses | 100% Covered |
| Lenses (per pair): Single | 100% Covered |
| Bifocal | 100% Covered |
| Trifocal | 100% Covered |
| Lenticular | 100% Covered |
| Contact Lenses: Contact lenses (in lieu of glasses) | 100% Covered |
| Contact lens fitting | 100% Covered |
| Specialty lens fitting | 100% Covered |
| Adult Vision | |
| Exams and Eyewear: Routine Eye Exam | 100% Covered |
| Eyeglasses | Covered up to $130 |
| Lenses(per pair): Single | 100% Covered |
| Bifocal | 100% Covered |
| Trifocal | 100% Covered |
| Lenticular | 100% Covered |
| Contact Lenses (in lieu of glasses) | Covered up to $130 |
| Contact lens fitting | 100% Covered |
| Specialty lens fitting | Covered up to $50 |
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New Enrollments: Phone: (312) 726-6565 Email: [email protected]