Ambetter from MHS

Ambetter Essential Care: $1,500 Medical Deductible + Vision + Adult Dental

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Medical Deductible	Individual: $1,500.00 Family: $3,000 Per Person: $1,500
Prescription Drug Deductible	Individual: $3,800.00 Family: $7,600 Per Person: $3,800
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,700.00 Family: $17,400 Per Person: $8,700

Office Visit

Primary Doctor	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge, except for HSAs.
Specialist	CoPay: $125.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $195.00 CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: $250.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Generic Drugs	CoPay: $31.40 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Most Ambetter Plans offer Preferred Generic Drugs at $5 or less. Please see plan's Summary of Benefits and Coverage (SBC) or policy document for Preferred Generic and Generic prescription drug cost.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: $3,000.00 Copay per Day after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Maximum 60 days per Benefit Period for Physical Medicine and Rehabilitation (includes Day Rehabilitation Therapy services on an Outpatient basis). Limit is combined both In and Out of Network.
Inpatient Services	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $2,500.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: $3,000.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Pre and Postnatal Office Visit	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per Year

Major Dental Care

Routine Dental Checkups for Children	Covered: Not Covered
Routine Dental Checkups for Adults	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered Limit Quantity: 1000 Limit Unit : Dollars per Year Benefit Explanation: $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults

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