Ambetter SilverSummit

Ambetter Balanced Care 32 + Vision + Adult Dental

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: $8,100 Family: $16,200 Per Person: $8,100
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $8,700 Family: $17,400 Per Person: $8,700
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: $45 Copay
Specialist	Standard: $100 Copay

Prescription Drug Information

Preferred Brand Drugs	Standard: $75 Copay
Non Preferred Brand Drugs	Standard: 50% Coinsurance after deductible
Generic Drugs	Standard: $22.60 Copay
Specialty Drugs	Standard: 50% Coinsurance after deductible

Inpatient Coverage

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

Emergency and Urgent Care

Emergency Room

Standard: 50% Coinsurance after deductible

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