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The amounts shown are what the member pays
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Plan Type – All HMO Ambetter Balanced Care #11 Ambetter Balanced Care #4 BlueCross Pathway X Guided 37UB BlueCross Pathway X Guided 37UV Kaiser 5000/50 Kaiser 4700/35
Plan Name Ambetter Balance Care 11 Ambetter Balanced Care 4 BlueCross 37UB BlueCross 37UV Kaiser 5000/50 Kaiser 4700/35
Metal Level Silver
Preventive Care
government list
100% Coverage – Member Pays Nothing; List of Covered Services
Deductible
Individual / Family
$6,000 / $12,000 $7,050 / $14,100 $5,300 / $10,600 $4,950 / $9,900 $5,000 / $10,000 $4,700 / $9,400
Coinsurance Deductible then 40% Deductible then 0% Deductible then 50% Deductible then 35% Deductibe then 35% Deductible then 35%
Maximum Out of Pocket
Individual / Family
$7,900/$15,800 $7,050 / $14,100 $7,900 / $15,800 $6,500 / $13,000 $7,350 / $14,700 $7,350 / $14,700
Dr Office Copay               PCP/Specialist/UrgentCare $30/$60/$100 $30/$60/$100 $35/ Ded then 25%/ Ded then $50 $35/ Ded then 35%/ Ded – $50 then 35% $50 – max 2/ $70- max 2/ $100 $35/$65/ $100
All Lab / X-rays & Imaging Deductible then 40% Deductible then 0% Deductible then $300 / 50% Deductible then $500 / 50% Deductibe then $550 Deductible then 35%
Emergency Room Deductible then 40% Deductible then 0% Deductible then $500 / 25% Deductible then $500 / 35% Deductibe then 35% Deductible then 35%
Inpatient / Outpatient
Hospital & Surgery
Deductible then 40% Deductible then 0% Deductible then 50% Deductible then $500 / 50% Deductibe then 35% Deductible then 35%
Rx Deductible Tier 1-2 No Ded; Tier 3,4 Medical Ded 40% Tiers 1-2 No Ded; Tiers 3-4 Med Ded 0% Tiers 1,2 No Ded; Tiers 3, 4 Med Ded 40% Tiers 1,2 No Ded;  Tiers 3, 4 Med Ded 40% Tier 1 – 2 No Ded; Tier 3, 4,5 $1,500 Ded Tier 1-2 No Ded; Tier 3,4,5 Med Ded
Rx Copays $20/$50/Med Ded then 40% $15/$50/ Med Ded 0%/0% $10/ $40/ Med Ded 40%/ 40% $10/ $40 / Med Ded 40%/ 40% $5/$35 $1,500 Ded 50%/50%/50% $5/$15 Med Ded $45/50%/50%
Benefits shown are for services at In-Network Providers. There is No Coverage for Out of Network Providers, except for Emergencies
Rates shown for Ambetter & BlueCross residents of counties:  Cherokee, Cobb, Dekalb, Douglas, Fayette, Forsyth, Fulton, Gwinnett, & Henry
Rates shown for Kaiser residents of counties: Clayton, Cobb, DeKalb, Fulton, Gwinnett and Henry – Other Kaiser counties are 10% higher
For rates in other counties please use the “Online Quotes” link on the 2019 Recommended Plans page
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 week on average in the last 6 months.
Please see plan brochure for a complete listing of benefit details, plan limitations and exclusions.

Add the rate for the age of each family member to be insured. There is no family discount.

Ambetter Balanced Care #11 Ambetter Balanced Care #4 BlueCross 37UB BlueCross 37UV Kaiser 5000/50 Kaiser 4700/35
Per Child Age 0-14 $263 $277 $266 $278 $257 $316
Age 15 $287 $302 $290 $303 $280 $345
Age 16 $296 $311 $299 $312 $289 $356
Age 17 $305 $321 $308 $322 $298 $367
Age 18 $314 $330 $317 $331 $307 $377
Age 19 $324 $341 $328 $342 $316 $389
Age 20 $334 $351 $338 $353 $326 $401
Age 21-24 $344 $362 $348 $363 $336 $413
Age 25 $345 $363 $349 $364 $337 $415
Age 26 $352 $370 $356 $372 $344 $423
Age 27 $361 $380 $365 $381 $353 $434
Age 28 $374 $393 $378 $395 $365 $449
Age 29 $385 $405 $389 $406 $376 $463
Age 30 $391 $411 $395 $412 $381 $469
Age 31 $399 $420 $403 $421 $390 $480
Age 32 $407 $428 $412 $430 $397 $489
Age 33 $412 $433 $417 $435 $402 $495
Ambetter Balanced Care #11 Ambetter Balanced Care #4 BlueCross 37UB BlueCross 37UV Kaiser 5000/50 Kaiser 4700/35
Age 34 $418 $440 $423 $441 $408 $502
Age 35 $421 $443 $426 $444 $411 $506
Age 36 $423 $445 $428 $447 $413 $508
Age 37 $426 $448 $431 $450 $416 $512
Age 38 $429 $451 $434 $453 $419 $516
Age 39 $434 $456 $439 $458 $424 $522
Age 40 $440 $463 $445 $465 $430 $529
Age 41 $448 $471 $453 $473 $437 $538
Age 42 $456 $479 $461 $481 $445 $548
Age 43 $467 $491 $472 $493 $456 $561
Age 44 $481 $506 $486 $508 $470 $578
Age 45 $497 $523 $503 $525 $485 $597
Age 46 $516 $543 $522 $545 $504 $620
Age 47 $538 $566 $544 $568 $525 $647
Age 48 $563 $592 $569 $594 $550 $677
Age 49 $587 $617 $594 $620 $573 $705
Age 50 $615 $647 $622 $649 $601 $739
Age 51 $642 $675 $649 $678 $627 $772
Age 52 $672 $707 $679 $709 $656 $808
Age 53 $702 $738 $710 $741 $686 $844
Ambetter Balanced Care #11 Ambetter Balanced Care #4 BlueCross 37UB BlueCross 37UV Kaiser 5000/50 Kaiser 4700/35
Age 54 $735 $773 $743 $776 $718 $883
Age 55 $767 $807 $776 $810 $749 $922
Age 56 $803 $844 $812 $848 $784 $965
Age 57 $839 $882 $848 $886 $819 $1,008
Age 58 $877 $922 $887 $926 $856 $1,054
Age 59 $896 $942 $906 $946 $875 $1,077
Age 60 $934 $982 $944 $986 $912 $1,123
Age 61 $967 $1,017 $978 $1,021 $944 $1,162
Age 62 $989 $1,040 $1,000 $1,044 $966 $1,189
Age 63 $1,016 $1,068 $1,027 $1,073 $992 $1,221
Age 64 $1,032 $1,085 $1,043 $1,089 $1,008 $1,240
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