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The amounts shown are what the member pays
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Plan Type – All HMO Ambetter Secure Care 1 Kaiser Gold 1500/20
Plan Name Ambetter Secure Care 1 Kaiser 1500/20
Metal Level Gold Gold
Preventive Care
government list
100% Coverage – List of Covered Services
Deductible
Individual / Family
$1,000 / $2,000 $1,500 / $3,000
Coinsurance Deductibe then 20% Deductibe then 30%
Maximum Out of Pocket
Individual / Family
$6,350 / $12,700 $5,000 / $10,000
Dr Office Copay               PCP/Specialist/UrgentCare Deductibe then 20% $20/$40/$75
All Lab / X-rays & Imaging Deductibe then 20% Deductibe then 30%
Emergency Room Deductibe then $250 Deductibe then 30%
Inpatient / Outpatient
Hospital & Surgery
Deductible then 20% Deductibe then 30%
Rx Deductible Tier 1 No Ded; Tier 2,3, 4  $500 Ded Tier 1 -2 No Deductible Tier 3, 4, 5 $500 Ded
Rx Copays $10/$25/$75/30% $5/$10/$30/45%/45%
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 Secure Care 1 Kaiser Gold 1500/20
Per Child Age 0-14 $296 $350
Age 15 $323 $382
Age 16 $333 $394
Age 17 $344 $406
Age 18 $354 $418
Age 19 $365 $431
Age 20 $376 $445
Age 21-24 $387 $458
Age 25 $389 $459
Age 26 $397 $469
Age 27 $407 $481
Age 28 $421 $498
Age 29 $434 $513
Age 30 $441 $520
Age 31 $449 $531
Age 32 $458 $542
Age 33 $464 $549
Ambetter Secure Care 1 Kaiser Gold 1500/20
Age 34 $471 $557
Age 35 $474 $561
Age 36 $476 $563
Age 37 $480 $567
Age 38 $483 $571
Age 39 $489 $578
Age 40 $496 $586
Age 41 $505 $596
Age 42 $514 $607
Age 43 $526 $622
Age 44 $542 $640
Age 45 $560 $662
Age 46 $581 $687
Age 47 $606 $716
Age 48 $634 $750
Age 49 $661 $782
Age 50 $693 $819
Age 51 $723 $855
Age 52 $757 $895
Age 53 $791 $935
Ambetter Secure Care 1 Kaiser Gold 1500/20
Age 54 $828 $979
Age 55 $864 $1,021
Age 56 $905 $1,069
Age 57 $945 $1,117
Age 58 $988 $1,168
Age 59 $1,009 $1,193
Age 60 $1,052 $1,244
Age 61 $1,089 $1,287
Age 62 $1,114 $1,317
Age 63 $1,144 $1,353
Age 64 $1,162 $1,374
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