Ambetter Health

Ambetter Secure Care 5

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Plan Overview

Medical Deductible	Individual: $1,450 Family: $2,900 Per Person: $1,450
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 $15 Out of network: Benefit not covered
Specialist	Standard: In network: You pay $35 Out of network: Benefit not covered

Prescription Drug Information

Preferred Brand Drugs	Standard: In network: You pay $30 Out of network: Benefit not covered
Non Preferred Brand Drugs	Standard: In network: You pay up to the deductible / 25% of the cost of care 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 / 30% of the cost of care after you meet your deductible Out of network: Benefit not covered

Inpatient Coverage

Hospital Services	Standard: In network: You pay up to the deductible / 20% of the cost of care after you meet your deductible Out of network: Benefit not covered
Inpatient Services	Standard: In network: You pay up to the deductible / 20% of the cost of care 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 / 20% of the cost of care after you meet your deductible Out of network: You pay up to the deductible / 20% of the cost of care after you meet your deductible