Ambetter SilverSummit

Ambetter Secure Care 5

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: $1,450 Family: $2,900 Per Person: $1,450
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $6,300 Family: $12,600 Per Person: $6,300
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

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

Prescription Drug Information

Preferred Brand Drugs	Standard: $30 Copay
Non Preferred Brand Drugs	Standard: 30% Coinsurance after deductible
Generic Drugs	Standard: $13.80 Copay
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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