The amounts shown are what the member pays
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| Plan Type – All HMO | Ambetter Balanced Care #11 | Ambetter Balanced Care #4 | BlueCross Pathway X Guided 37UB | BlueCross Pathway X Guided 37UV | Kaiser 5000/50 | Kaiser 4700/35 |
| Plan Name | Ambetter Balance Care 11 | Ambetter Balanced Care 4 | BlueCross 37UB | BlueCross 37UV | Kaiser 5000/50 | Kaiser 4700/35 |
| Metal Level | Silver | |||||
| Preventive Care government list |
100% Coverage – Member Pays Nothing; List of Covered Services | |||||
| Deductible Individual / Family |
$6,000 / $12,000 | $7,050 / $14,100 | $5,300 / $10,600 | $4,950 / $9,900 | $5,000 / $10,000 | $4,700 / $9,400 |
| Coinsurance | Deductible then 40% | Deductible then 0% | Deductible then 50% | Deductible then 35% | Deductibe then 35% | Deductible then 35% |
| Maximum Out of Pocket Individual / Family |
$7,900/$15,800 | $7,050 / $14,100 | $7,900 / $15,800 | $6,500 / $13,000 | $7,350 / $14,700 | $7,350 / $14,700 |
| Dr Office Copay PCP/Specialist/UrgentCare | $30/$60/$100 | $30/$60/$100 | $35/ Ded then 25%/ Ded then $50 | $35/ Ded then 35%/ Ded – $50 then 35% | $50 – max 2/ $70- max 2/ $100 | $35/$65/ $100 |
| All Lab / X-rays & Imaging | Deductible then 40% | Deductible then 0% | Deductible then $300 / 50% | Deductible then $500 / 50% | Deductibe then $550 | Deductible then 35% |
| Emergency Room | Deductible then 40% | Deductible then 0% | Deductible then $500 / 25% | Deductible then $500 / 35% | Deductibe then 35% | Deductible then 35% |
| Inpatient / Outpatient Hospital & Surgery |
Deductible then 40% | Deductible then 0% | Deductible then 50% | Deductible then $500 / 50% | Deductibe then 35% | Deductible then 35% |
| Rx Deductible | Tier 1-2 No Ded; Tier 3,4 Medical Ded 40% | Tiers 1-2 No Ded; Tiers 3-4 Med Ded 0% | Tiers 1,2 No Ded; Tiers 3, 4 Med Ded 40% | Tiers 1,2 No Ded; Tiers 3, 4 Med Ded 40% | Tier 1 – 2 No Ded; Tier 3, 4,5 $1,500 Ded | Tier 1-2 No Ded; Tier 3,4,5 Med Ded |
| Rx Copays | $20/$50/Med Ded then 40% | $15/$50/ Med Ded 0%/0% | $10/ $40/ Med Ded 40%/ 40% | $10/ $40 / Med Ded 40%/ 40% | $5/$35 $1,500 Ded 50%/50%/50% | $5/$15 Med Ded $45/50%/50% |
| Benefits shown are for services at In-Network Providers. There is No Coverage for Out of Network Providers, except for Emergencies | ||||
| Rates shown for Ambetter & BlueCross residents of counties: Cherokee, Cobb, Dekalb, Douglas, Fayette, Forsyth, Fulton, Gwinnett, & Henry | ||||
| Rates shown for Kaiser residents of counties: Clayton, Cobb, DeKalb, Fulton, Gwinnett and Henry – Other Kaiser counties are 10% higher | ||||
| For rates in other counties please use the “Online Quotes” link on the 2019 Recommended Plans page | ||||
| 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 week on average in the last 6 months. | ||||
| Please see plan brochure for a complete listing of benefit details, plan limitations and exclusions. |
Add the rate for the age of each family member to be insured. There is no family discount.
| Ambetter Balanced Care #11 | Ambetter Balanced Care #4 | BlueCross 37UB | BlueCross 37UV | Kaiser 5000/50 | Kaiser 4700/35 | |
| Per Child Age 0-14 | $263 | $277 | $266 | $278 | $257 | $316 |
| Age 15 | $287 | $302 | $290 | $303 | $280 | $345 |
| Age 16 | $296 | $311 | $299 | $312 | $289 | $356 |
| Age 17 | $305 | $321 | $308 | $322 | $298 | $367 |
| Age 18 | $314 | $330 | $317 | $331 | $307 | $377 |
| Age 19 | $324 | $341 | $328 | $342 | $316 | $389 |
| Age 20 | $334 | $351 | $338 | $353 | $326 | $401 |
| Age 21-24 | $344 | $362 | $348 | $363 | $336 | $413 |
| Age 25 | $345 | $363 | $349 | $364 | $337 | $415 |
| Age 26 | $352 | $370 | $356 | $372 | $344 | $423 |
| Age 27 | $361 | $380 | $365 | $381 | $353 | $434 |
| Age 28 | $374 | $393 | $378 | $395 | $365 | $449 |
| Age 29 | $385 | $405 | $389 | $406 | $376 | $463 |
| Age 30 | $391 | $411 | $395 | $412 | $381 | $469 |
| Age 31 | $399 | $420 | $403 | $421 | $390 | $480 |
| Age 32 | $407 | $428 | $412 | $430 | $397 | $489 |
| Age 33 | $412 | $433 | $417 | $435 | $402 | $495 |
| Ambetter Balanced Care #11 | Ambetter Balanced Care #4 | BlueCross 37UB | BlueCross 37UV | Kaiser 5000/50 | Kaiser 4700/35 | |
| Age 34 | $418 | $440 | $423 | $441 | $408 | $502 |
| Age 35 | $421 | $443 | $426 | $444 | $411 | $506 |
| Age 36 | $423 | $445 | $428 | $447 | $413 | $508 |
| Age 37 | $426 | $448 | $431 | $450 | $416 | $512 |
| Age 38 | $429 | $451 | $434 | $453 | $419 | $516 |
| Age 39 | $434 | $456 | $439 | $458 | $424 | $522 |
| Age 40 | $440 | $463 | $445 | $465 | $430 | $529 |
| Age 41 | $448 | $471 | $453 | $473 | $437 | $538 |
| Age 42 | $456 | $479 | $461 | $481 | $445 | $548 |
| Age 43 | $467 | $491 | $472 | $493 | $456 | $561 |
| Age 44 | $481 | $506 | $486 | $508 | $470 | $578 |
| Age 45 | $497 | $523 | $503 | $525 | $485 | $597 |
| Age 46 | $516 | $543 | $522 | $545 | $504 | $620 |
| Age 47 | $538 | $566 | $544 | $568 | $525 | $647 |
| Age 48 | $563 | $592 | $569 | $594 | $550 | $677 |
| Age 49 | $587 | $617 | $594 | $620 | $573 | $705 |
| Age 50 | $615 | $647 | $622 | $649 | $601 | $739 |
| Age 51 | $642 | $675 | $649 | $678 | $627 | $772 |
| Age 52 | $672 | $707 | $679 | $709 | $656 | $808 |
| Age 53 | $702 | $738 | $710 | $741 | $686 | $844 |
| Ambetter Balanced Care #11 | Ambetter Balanced Care #4 | BlueCross 37UB | BlueCross 37UV | Kaiser 5000/50 | Kaiser 4700/35 | |
| Age 54 | $735 | $773 | $743 | $776 | $718 | $883 |
| Age 55 | $767 | $807 | $776 | $810 | $749 | $922 |
| Age 56 | $803 | $844 | $812 | $848 | $784 | $965 |
| Age 57 | $839 | $882 | $848 | $886 | $819 | $1,008 |
| Age 58 | $877 | $922 | $887 | $926 | $856 | $1,054 |
| Age 59 | $896 | $942 | $906 | $946 | $875 | $1,077 |
| Age 60 | $934 | $982 | $944 | $986 | $912 | $1,123 |
| Age 61 | $967 | $1,017 | $978 | $1,021 | $944 | $1,162 |
| Age 62 | $989 | $1,040 | $1,000 | $1,044 | $966 | $1,189 |
| Age 63 | $1,016 | $1,068 | $1,027 | $1,073 | $992 | $1,221 |
| Age 64 | $1,032 | $1,085 | $1,043 | $1,089 | $1,008 | $1,240 |
