Ambetter SilverSummit

Ambetter Balanced Care 11 + Vision + Adult Dental

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: $6,000 Family: $12,000 Per Person: $6,000
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $8,500 Family: $17,000 Per Person: $8,500
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: $30 Copay
Specialist	Standard: $60 Copay

Prescription Drug Information

Preferred Brand Drugs	Standard: $55 Copay
Non Preferred Brand Drugs	Standard: 50% Coinsurance after deductible
Generic Drugs	Standard: $18.20 Copay
Specialty Drugs	Standard: 50% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: 40% Coinsurance after deductible
Inpatient Services	Standard: 40% Coinsurance after deductible

Emergency and Urgent Care

Emergency Room

Standard: 40% Coinsurance after deductible

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