Ambetter SilverSummit

Ambetter Value Bronze: $1,500 Medical Deductible

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: $1,500 Family: $3,000 Per Person: $1,500
Prescription Drug Deductible	Individual: $3,800 Family: $7,600 Per Person: $3,800
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: $40 Copay
Specialist	Standard: $125 Copay

Prescription Drug Information

Preferred Brand Drugs	Standard: $195 Copay
Non Preferred Brand Drugs	Standard: $250 Copay after deductible
Generic Drugs	Standard: $31.40 Copay
Specialty Drugs	Standard: 50% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: $3000 Copay per day after deductible
Inpatient Services	Standard: No Charge

Emergency and Urgent Care

Emergency Room

Standard: $2500 Copay after deductible

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