Ambetter Health

Ambetter Secure Care 5 + Vision + Adult Dental

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Summary Of Benefits

Plan Overview

Medical Deductible	Individual: $1,450 Family: $2,900 Per Person: $1,450
Prescription Drug Deductible	Individual: Included in Deductible Family: Included in Deductible Per Person: Included in Deductible
Medical Out-of-Pocket Maximum	Individual: $6,500 Family: $13,000 Per Person: $6,500
Drug Out-of-Pocket Maximum	Individual: Included in Deductible Family: Included in Deductible Per Person: Included in Deductible

Office Visit

Primary Doctor	Standard: $15 Copay
Specialist	Standard: $35 Copay

Prescription Drug Information

Preferred Brand Drugs	Standard: $30
Non Preferred Brand Drugs	Standard: 30% Coinsurance after deductible
Generic Drugs	Standard: $15
Specialty Drugs	Standard: 30% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: 20% Coinsurance after deductible
Inpatient Services	Standard: 20% Coinsurance after deductible

Emergency and Urgent Care

Emergency Room

Standard: 20% Coinsurance after deductible

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