Ambetter SilverSummit

Ambetter Balanced Care 28

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: $0 Family: $0 Per Person: $0
Prescription Drug Deductible	Individual: $1,500 Family: $3,000 Per Person: $1,500
Medical Out-of-Pocket Maximum	Individual: $8,200 Family: $16,400 Per Person: $8,200
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: $50 Copay
Specialist	Standard: $90 Copay

Prescription Drug Information

Preferred Brand Drugs	Standard: 50% Coinsurance after deductible
Non Preferred Brand Drugs	Standard: 50% Coinsurance after deductible
Generic Drugs	Standard: $27 Copay
Specialty Drugs	Standard: 50% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: 50% Coinsurance
Inpatient Services	Standard: 50% Coinsurance

Emergency and Urgent Care

Emergency Room

Standard: 50% Coinsurance

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