Ambetter SilverSummit

Elite Gold

Plan Overview

Medical Deductible
  • Individual: $0
  • Family: $0
  • Per Person: $0
Prescription Drug Deductible
  • Individual: Included in Medical
  • Family: Included in Medical
  • Per Person: Included in Medical
Medical Out-of-Pocket Maximum
  • Individual: $5,500
  • Family: $11,000
  • Per Person: $5,500
Drug Out-of-Pocket Maximum
  • Individual: Included in Medical
  • Family: Included in Medical
  • Per Person: Included in Medical

Office Visit

Primary Doctor
  • Standard: $5 Copay
Specialist
  • Standard: $60 Copay

Prescription Drug Information

Preferred Brand Drugs
  • Standard: $50 Copay
Non Preferred Brand Drugs
  • Standard: 45% Coinsurance
Generic Drugs
  • Standard: $3 Copay
Specialty Drugs
  • Standard: 50% Coinsurance

Inpatient Coverage

Hospital Services
  • Standard: 30% Coinsurance
Inpatient Services
  • Standard: 30% Coinsurance

Emergency and Urgent Care

Emergency Room
  • Standard: 30% Coinsurance