Ambetter Health

Ambetter Balanced Care 4

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: $8,050 Family: $16,100 Per Person: $8,050
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: In network: You pay $30 Out of network: Benefit not covered
Specialist	Standard: In network: You pay $60 Out of network: Benefit not covered

Prescription Drug Information

Preferred Brand Drugs	Standard: In network: You pay $50 Out of network: Benefit not covered
Non Preferred Brand Drugs	Standard: In network: You pay up to the deductible / Covered at no cost to you after you meet your deductible Out of network: Benefit not covered
Generic Drugs	Standard: In network: You pay $3 for preferred generic drugs and $15 for generic drugs Out of network: Benefit not covered
Specialty Drugs	Standard: In network: You pay up to the deductible / Covered at no cost to you after you meet your deductible Out of network: Benefit not covered

Inpatient Coverage

Hospital Services	Standard: In network: You pay up to the deductible / Covered at no cost to you after you meet your deductible Out of network: Benefit not covered
Inpatient Services	Standard: In network: You pay up to the deductible / Covered at no cost to you after you meet your deductible Out of network: Benefit not covered

Emergency and Urgent Care

Emergency Room

Standard: In network: You pay up to the deductible / Covered at no cost to you after you meet your deductible Out of network: You pay up to the deductible / Covered at no cost to you after you meet your deductible