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 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 | |
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 |