The amounts are what the member pays
| Plan Type | Bronze HSA HMO | Silver Copay #4 HMO | Silver Copay #2 HMO | Silver Copay #1 HMO | Gold Secure Care #1 HMO |
| Plan Name | Ambetter Essential Care 2 HSA | Ambetter Balanced Care 4 | Ambetter Balanced Care 2 | Ambetter Balanced Care 1 | Ambetter Secure Care 1 |
| Network | Ambetter HMO | ||||
| Preventive Care government list |
Free Preventative Care List of Covered Services | ||||
| Deductible Individual / Family |
$6,550 / $13,100 | $7,050 / $14,100 | $6,500 / $13,000 | $5,500 / $11,000 | $1,000 / $2,000 |
| Coinsurance | Deductible then 0% | Deductible then 0% | Deductible then 0% | Deductible then 20% | Deductible then 20% |
| Maximum Out of Pocket Individual / Family (Includes Medical Ded, Rx Ded, Coinsurance and Copays) |
$6,550 / $13,100 | $7,050 / $14,100 | $6,500 / $13,000 | $6,500 / $13,000 | $6,350 / $12,700 |
| Dr Office Copay PCP/Specialist/UrgentCare | Deductible then 0% | $30/$60/$100 | $30/$60/$100 | $30/$60/$100 | PCP - 3 Free Visits Specialist / UC Ded + 20% |
| All Lab / X-rays & Imaging | Deductible then 0% | Deductible then 0% | Deductible then 0% | Deductible then 20% | Deductible then 20% |
| Emergency Room | Deductible then 0% | Deductible then 0% | Deductible then 0% | Deductible then 20% | $250 + Deductible + 20% |
| Inpatient / Outpatient Hospital & Surgery |
Deductible then 0% | Deductible then 0% | Deductible then 0% | Deductible then 20% | Deductible then 20% |
| Rx Deductible | Combined with Medical | Tiers 1-2 No Ded, Tiers 3-4 Combined with Medical Ded | Tiers 1-2 No Ded, Tiers 3-4 Combined with Medical Ded | Tiers 1-2 No Ded, Tiers 3-4 Combined with Medical Ded | Tier 1 No Ded Tier 2,3, 4 $500 |
| Rx Copays ** | Ded then 0% | $15/$50 | $15/$50 | $15/$50 | $10/$25/$75/30% |
| Benefits shown are for services at In-Network Providers. There is No Coverage for Out of Network Providers, except for Emergencies | |||||
| Please see plan brochure for a complete listing of benefit details, plan limitations and exclusions. | |||||
| Rates shown are for non-tobacco users, within + / - $5; regular tobacco user rates will be approx. 15% higher. Regular use = 4 or more times per week on average in the last 6 months. | |||||
| *Area 2 Counties: Barrow, Clarke, Elbert, Greene, Jackson, Madison, Oconee | |||||
| ** Rx - Tier 1 Generic, Tier 2 Preferred Brand, Tier 3 Non-preferred Brand, Tier 4 Specialty Drugs | |||||
| Add the rate for the age of each family member to be covered. There is no family discount. | |||||
| Bronze HSA HMO | Silver Copay #4 HMO | Silver Copay #2 HMO | Silver Copay #1 HMO | Gold Secure Care #1 HMO | |
| Per Child Age 0-14 | $210 | $231 | $239 | $243 | $258 |
| Age 15 | $229 | $252 | $260 | $265 | $281 |
| Age 16 | $235 | $260 | $268 | $272 | $289 |
| Age 17 | $243 | $268 | $276 | $281 | $298 |
| Age 18 | $251 | $276 | $285 | $290 | $308 |
| Age 19 | $259 | $285 | $294 | $299 | $318 |
| Age 20 | $266 | $293 | $303 | $308 | $327 |
| Age 21-24 | $274 | $302 | $312 | $317 | $337 |
| Age 25 | $275 | $303 | $313 | $318 | $338 |
| Age 26 | $281 | $310 | $319 | $325 | $345 |
| Age 27 | $288 | $317 | $327 | $333 | $353 |
| Age 28 | $298 | $329 | $340 | $345 | $367 |
| Age 29 | $307 | $338 | $349 | $355 | $377 |
| Age 30 | $311 | $343 | $354 | $360 | $383 |
| Age 31 | $318 | $350 | $362 | $368 | $391 |
| Age 32 | $324 | $358 | $369 | $375 | $399 |
| Age 33 | $329 | $363 | $374 | $381 | $404 |
| Age 34 | $333 | $367 | $379 | $385 | $409 |
| Age 35 | $336 | $370 | $382 | $388 | $412 |
| Age 36 | $337 | $372 | $384 | $390 | $415 |
| Age 37 | $339 | $374 | $386 | $392 | $417 |
| Age 38 | $342 | $377 | $389 | $396 | $420 |
| Age 39 | $347 | $382 | $394 | $401 | $426 |
| Age 40 | $350 | $386 | $399 | $405 | $430 |
| Age 41 | $357 | $393 | $406 | $413 | $438 |
| Age 42 | $363 | $401 | $413 | $420 | $446 |
| Age 43 | $373 | $411 | $424 | $431 | $458 |
| Age 44 | $384 | $423 | $437 | $444 | $471 |
| Age 45 | $396 | $436 | $450 | $458 | $486 |
| Age 46 | $412 | $454 | $468 | $476 | $506 |
| Age 47 | $429 | $473 | $488 | $497 | $527 |
| Age 48 | $449 | $495 | $510 | $519 | $551 |
| Age 49 | $468 | $516 | $532 | $542 | $575 |
| Age 50 | $490 | $540 | $557 | $567 | $602 |
| Age 51 | $512 | $564 | $582 | $592 | $629 |
| Age 52 | $536 | $591 | $609 | $620 | $658 |
| Age 53 | $560 | $617 | $637 | $648 | $688 |
| Bronze HSA HMO | Silver Copay #4 HMO | Silver Copay #2 HMO | Silver Copay #1 HMO | Gold Secure Care #1 HMO | |
| Age 54 | $586 | $646 | $666 | $678 | $720 |
| Age 55 | $612 | $674 | $696 | $708 | $752 |
| Age 56 | $640 | $706 | $729 | $741 | $787 |
| Age 57 | $668 | $737 | $760 | $773 | $821 |
| Age 58 | $699 | $770 | $795 | $809 | $859 |
| Age 59 | $715 | $788 | $813 | $827 | $878 |
| Age 60 | $745 | $821 | $847 | $862 | $915 |
| Age 61 | $771 | $850 | $877 | $892 | $948 |
| Age 62 | $788 | $869 | $896 | $912 | $968 |
| Age 63 | $810 | $893 | $922 | $937 | $995 |
| Age 64 | $823 | $907 | $936 | $952 | $1,011 |
