Ambetter of North Carolina Inc.

Ambetter Balanced Care 11 + Vision + Adult Dental

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $6,000.00 Family: $12,000 Per Person: $6,000
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,500.00 Family: $17,000 Per Person: $8,500

Office Visit

Primary Doctor	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge, except for HSAs.
Specialist	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $55.00 CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered
Generic Drugs	CoPay: $18.20 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: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Note: Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization.
Urgent Care Facility	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: $30.00 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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