Enhanced Diabetes Care Silver with $0 Drug Options + Vision + Adult Dental
Ambetter of Tennessee
Plan overview
Medical deductible
Individual: $5000
Family: $10000
Per Person: $5000
Prescription drug deductible
Individual: $0
Family: $0
Per Person: $0
Combined medical and drug out of pocket maximum
Individual: $8650
Family: $17300
Per Person: $8650
Office visit
Primary Doctor
CoPay: $30.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Unlimited Virtual 24/7 Care Visits received from Ambetter’s designated telehealth provider covered at No Charge, except for HSAs. Primary care visits provided to treat a behavioral health diagnosis fall under mental/behavioral health services.
Specialist
CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Specialist visits provided to treat a behavioral health diagnosis fall under mental/behavioral health services.
Prescription drug information
Preferred brand drugs
CoPay: $60.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Enhanced diabetes drugs from a Network Pharmacy covered at no cost.
Non preferred brand drugs
CoPay: Not Applicable
CoInsurance: 45.00% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
Generic drugs
CoPay: $3.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Cost sharing shown applies to Tier 1a-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 1b-Generic Drugs, which may apply a higher cost share. Up to a 30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. Refer to the prescription drug list for more information. Enhanced diabetes drugs from a Network Pharmacy covered at no cost.
Specialty drugs
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
Inpatient coverage
Hospital services
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Inpatient services
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Emergency and urgent care
Emergency room
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Urgent care facility
CoPay: $50.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation:
Maternity
Labor and delivery hospital stay
CoPay: Not Applicable
CoInsurance: 50.00% Coinsurance after deductible
Covered: Covered
Pre and Postnatal office visit
CoPay: $30.00
CoInsurance: Not Applicable
Covered: Covered
Vision
Routine Eye Exams for Children
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit: Exam(s) per Year
Major dental care
Routine dental checkups for children
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Routine dental checkups for adults
CoPay: No Charge
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1000
Limit Unit: Dollars per Year
Benefit Explanation: $1,000 annual benefit maximum includes all Dental services (Routine, Basic and Major) for Adults
These policies have exclusions, limitations, reduction of benefits, terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable).