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The amounts are what the member pays

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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 3 Counties: Butts, Cherokee, Clayton, Cobb, Dekalb, Douglas, Fayette, Forsyth, Fulton, Gwinnett, Henry, Paulding, Spalding, Walton
** 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
    1.1024 1.1376 1.1570 1.2286
Per Child Age 0-14 $226 $250 $258 $262 $278
Age 15 $247 $272 $281 $286 $303
Age 16 $254 $280 $289 $294 $312
Age 17 $262 $289 $298 $303 $322
Age 18 $270 $298 $307 $313 $332
Age 19 $279 $308 $317 $323 $343
Age 20 $287 $316 $326 $332 $353
Age 21-24 $296 $326 $337 $343 $364
Age 25 $297 $327 $338 $344 $365
Age 26 $303 $334 $345 $351 $372
Age 27 $310 $342 $353 $359 $381
Age 28 $322 $355 $366 $373 $396
Age 29 $331 $365 $377 $383 $407
Age 30 $336 $370 $382 $389 $413
Age 31 $343 $378 $390 $397 $421
Age 32 $350 $386 $398 $405 $430
Age 33 $355 $391 $404 $411 $436
Age 34 $359 $396 $408 $415 $441
Age 35 $362 $399 $412 $419 $445
Age 36 $364 $401 $414 $421 $447
Age 37 $366 $403 $416 $423 $450
Age 38 $369 $407 $420 $427 $453
Age 39 $374 $412 $425 $433 $459
Age 40 $378 $417 $430 $437 $464
Age 41 $385 $424 $438 $445 $473
Age 42 $392 $432 $446 $454 $482
Age 43 $402 $443 $457 $465 $494
Age 44 $414 $456 $471 $479 $509
Age 45 $427 $471 $486 $494 $525
Age 46 $444 $489 $505 $514 $545
Age 47 $463 $510 $527 $536 $569
Age 48 $484 $534 $551 $560 $595
Age 49 $505 $557 $574 $584 $620
Age 50 $529 $583 $601 $612 $650
Age 51 $552 $609 $628 $639 $678
Age 52 $578 $637 $658 $669 $710
Age 53 $604 $666 $687 $699 $742
  Bronze HSA HMO Silver Copay #4 HMO Silver Copay #2 HMO Silver Copay #1 HMO Gold Secure Care #1 HMO
Age 54 $632 $697 $719 $731 $776
Age 55 $660 $728 $751 $764 $811
Age 56 $691 $762 $786 $799 $849
Age 57 $721 $795 $820 $834 $886
Age 58 $754 $831 $858 $872 $926
Age 59 $771 $850 $877 $892 $947
Age 60 $803 $886 $914 $930 $987
Age 61 $832 $917 $946 $963 $1,022
Age 62 $850 $937 $967 $983 $1,044
Age 63 $874 $963 $994 $1,011 $1,074
Age 64 $888 $979 $1,010 $1,027 $1,091

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