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The amounts are what the member pays

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Plan Type Bronze HSA HMO Silver Copay #4 HMO Silver Copay #2 HMO Silver Copay #1 HMO Gold Secure Care #1 HMO
Plan Name Ambetter Essential Care 2 HSA Ambetter Balanced Care 4 Ambetter Balanced Care 2 Ambetter Balanced Care 1 Ambetter Secure Care 1
Network Ambetter HMO
Preventive Care
government list
Free Preventative Care List of Covered Services
Deductible
Individual / Family
$6,550 / $13,100 $7,050 / $14,100 $6,500 / $13,000 $5,500 / $11,000 $1,000 / $2,000
Coinsurance Deductible then 0% Deductible then 0% Deductible then 0% Deductible then 20% Deductible then 20%
Maximum Out of Pocket
Individual / Family
(Includes Medical Ded, Rx Ded, Coinsurance and Copays)
$6,550 / $13,100 $7,050 / $14,100 $6,500 / $13,000 $6,500 / $13,000 $6,350 / $12,700
Dr Office Copay PCP/Specialist/UrgentCare Deductible then 0% $30/$60/$100 $30/$60/$100 $30/$60/$100 PCP - 3 Free Visits
Specialist / UC Ded + 20%
All Lab / X-rays & Imaging Deductible then 0% Deductible then 0% Deductible then 0% Deductible then 20% Deductible then 20%
Emergency Room Deductible then 0% Deductible then 0% Deductible then 0% Deductible then 20% $250 + Deductible + 20%
Inpatient / Outpatient
Hospital & Surgery
Deductible then 0% Deductible then 0% Deductible then 0% Deductible then 20% Deductible then 20%
Rx Deductible Combined with Medical Tiers 1-2 No Ded, Tiers 3-4 Combined with Medical Ded Tiers 1-2 No Ded, Tiers 3-4 Combined with Medical Ded Tiers 1-2 No Ded, Tiers 3-4 Combined with Medical Ded Tier 1 No Ded
Tier 2,3, 4 $500
Rx Copays ** Ded then 0% $15/$50 $15/$50 $15/$50 $10/$25/$75/30%
Benefits shown are for services at In-Network Providers. There is No Coverage for Out of Network Providers, except for Emergencies
Please see plan brochure for a complete listing of benefit details, plan limitations and exclusions.
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 months.
*Area 2 Counties: Barrow, Clarke, Elbert, Greene, Jackson, Madison, Oconee
** Rx - Tier 1 Generic, Tier 2 Preferred Brand, Tier 3 Non-preferred Brand, Tier 4 Specialty Drugs
Add the rate for the age of each family member to be covered. There is no family discount.
  Bronze HSA HMO Silver Copay #4 HMO Silver Copay #2 HMO Silver Copay #1 HMO Gold Secure Care #1 HMO
    1.1024 1.1376 1.1570 1.2286
Per Child Age 0-14 $210 $231 $239 $243 $258
Age 15 $229 $252 $260 $265 $281
Age 16 $235 $260 $268 $272 $289
Age 17 $243 $268 $276 $281 $298
Age 18 $251 $276 $285 $290 $308
Age 19 $259 $285 $294 $299 $318
Age 20 $266 $293 $303 $308 $327
Age 21-24 $274 $302 $312 $317 $337
Age 25 $275 $303 $313 $318 $338
Age 26 $281 $310 $319 $325 $345
Age 27 $288 $317 $327 $333 $353
Age 28 $298 $329 $340 $345 $367
Age 29 $307 $338 $349 $355 $377
Age 30 $311 $343 $354 $360 $383
Age 31 $318 $350 $362 $368 $391
Age 32 $324 $358 $369 $375 $399
Age 33 $329 $363 $374 $381 $404
Age 34 $333 $367 $379 $385 $409
Age 35 $336 $370 $382 $388 $412
Age 36 $337 $372 $384 $390 $415
Age 37 $339 $374 $386 $392 $417
Age 38 $342 $377 $389 $396 $420
Age 39 $347 $382 $394 $401 $426
Age 40 $350 $386 $399 $405 $430
Age 41 $357 $393 $406 $413 $438
Age 42 $363 $401 $413 $420 $446
Age 43 $373 $411 $424 $431 $458
Age 44 $384 $423 $437 $444 $471
Age 45 $396 $436 $450 $458 $486
Age 46 $412 $454 $468 $476 $506
Age 47 $429 $473 $488 $497 $527
Age 48 $449 $495 $510 $519 $551
Age 49 $468 $516 $532 $542 $575
Age 50 $490 $540 $557 $567 $602
Age 51 $512 $564 $582 $592 $629
Age 52 $536 $591 $609 $620 $658
Age 53 $560 $617 $637 $648 $688
  Bronze HSA HMO Silver Copay #4 HMO Silver Copay #2 HMO Silver Copay #1 HMO Gold Secure Care #1 HMO
Age 54 $586 $646 $666 $678 $720
Age 55 $612 $674 $696 $708 $752
Age 56 $640 $706 $729 $741 $787
Age 57 $668 $737 $760 $773 $821
Age 58 $699 $770 $795 $809 $859
Age 59 $715 $788 $813 $827 $878
Age 60 $745 $821 $847 $862 $915
Age 61 $771 $850 $877 $892 $948
Age 62 $788 $869 $896 $912 $968
Age 63 $810 $893 $922 $937 $995
Age 64 $823 $907 $936 $952 $1,011
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