Ambetter Silver Plans

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If you’re looking for a balance on your monthly premium payments and your out-of-pocket costs, Silver plans provide just that. And, Silver plans are the only plans with additional out-of-pocket payment reductions (cost sharing reductions)! This helps lower the costs of your copays, deductibles and coinsurance.

Plan Name	Balanced Care 1 (2017) – Standard	Balanced Care 1 (2017) – 73% AV	Balanced Care 1 (2017) – 87% AV	Balanced Care 1 (2017) – 94% AV
Medical Deductible(Ind/Fam)	$5,500/$11,000	$3,500/$7,000	$450/$900	$0/$0
Prescription Drug Deductible(Ind/Fam)	Integrated with medical ded.	Integrated with medical ded.	Integrated with medical ded.	Integrated with medical ded.
Metal Level	Silver	Silver	Silver	Silver
Out-of-pocket Maximum(Ind/Fam)	$6,500/$13,000	$5,450/$10,900	$2,250/$4,500	$700/$1,400
Annual Well Visit/ Preventive Care	No charge	No charge	No charge	No charge
PCP Office Visit	$30	$20	$1	$1
Specialist Office Visit	$60	$30	$10	$10
Imaging(CT/PET Scans, MRIs)	20% after ded.	20% after ded.	20% after ded.	20% after ded.
X-rays & Diagnostic Imaging	20% after ded.	20% after ded.	20% after ded.	20% after ded.
Urgent Care	$100	$75	$50	$50
Emergency Room*	20% after ded.	20% after ded.	20% after ded.	20% after ded.
Emergency Transportation*	20% after ded.	20% after ded.	20% after ded.	20% after ded.
Inpatient Facility Fee	20% after ded.	20% after ded.	20% after ded.	20% after ded.
Inpatient Hospital Physician & Surgical Services	20% after ded.	20% after ded.	20% after ded.	20% after ded.
Outpatient Facility Fee	20% after ded.	20% after ded.	20% after ded.	20% after ded.
Outpatient Surgery Physician/Surgical Services	20% after ded.	20% after ded.	20% after ded.	20% after ded.
Labs & Diagnostics	20% after ded.	20% after ded.	20% after ded.	20% after ded.
Mental/Behavioral Health & Substance Use Disorder Outpatient Services	$30	$20	$1	$1
Rehabilitation Outpatient Services(Includes Speech, Occupational, Physical Therapy)	20% after ded.	20% after ded.	20% after ded.	20% after ded.
Skilled Nursing Facility	20% after ded.	20% after ded.	20% after ded.	20% after ded.
Pediatric Vision- Routine Eye Exam(1 visit per year)	100% Covered	100% Covered	100% Covered	100% Covered
Pediatric Vision- Eyeglasses(frames, 1 per year)	100% Covered	100% Covered	100% Covered	100% Covered
Pedicatric Vision- Lenses(per pair)	100% Covered	100% Covered	100% Covered	100% Covered

Plan Name	Balanced Care 2 (2017) – Standard	Balanced Care 2 (2017) – 73% AV	Balanced Care 2 (2017) – 87% AV	Balanced Care 2 (2017) – 94% AV
Medical Deductible(Ind/Fam)	$6,500/$13,000	$5,000/$10,000	$1,750/$3,500	$575/$1,150
Prescription Drug Deductible(Ind/Fam)	Integrated with medical ded.	Integrated with medical ded.	Integrated with medical ded.	Integrated with medical ded.
Metal Level	Silver	Silver	Silver	Silver
Out-of-pocket Maximum(Ind/Fam)	$6,500/$13,000	$5,000/$10,000	$1,750/$3,500	$575/$1,150
Annual Well Visit/ Preventive Care	No charge	No charge	No charge	No charge
PCP Office Visit	$30	$25	$1	$1
Specialist Office Visit	$60	$50	$5	$5
Imaging(CT/PET Scans, MRIs)	No charge after ded.	No charge after ded.	No charge after ded.	No charge after ded.
X-rays & Diagnostic Imaging	No charge after ded.	No charge after ded.	No charge after ded.	No charge after ded.
Urgent Care	$100	$75	$50	$50
Emergency Room*	No charge after ded.	No charge after ded.	No charge after ded.	No charge after ded.
Emergency Transportation*	No charge after ded.	No charge after ded.	No charge after ded.	No charge after ded.
Inpatient Facility Fee	No charge after ded.	No charge after ded.	No charge after ded.	No charge after ded.
Inpatient Hospital Physician & Surgical Services	No charge after ded.	No charge after ded.	No charge after ded.	No charge after ded.
Outpatient Facility Fee	No charge after ded.	No charge after ded.	No charge after ded.	No charge after ded.
Outpatient Surgery Physician/Surgical Services	No charge after ded.	No charge after ded.	No charge after ded.	No charge after ded.
Labs & Diagnostics	No charge after ded.	No charge after ded.	No charge after ded.	No charge after ded.
Mental/Behavioral Health & Substance Use Disorder Outpatient Services	$30	$25	$1	$1
Rehabilitation Outpatient Services(Includes Speech, Occupational, Physical Therapy)	No charge after ded.	No charge after ded.	No charge after ded.	No charge after ded.
Skilled Nursing Facility	No charge after ded.	No charge after ded.	No charge after ded.	No charge after ded.
Pediatric Vision- Routine Eye Exam(1 visit per year)	100% Covered	100% Covered	100% Covered	100% Covered
Pediatric Vision- Eyeglasses(frames, 1 per year)	100% Covered	100% Covered	100% Covered	100% Covered
Pedicatric Vision- Lenses(per pair)	100% Covered	100% Covered	100% Covered	100% Covered
Pharmacy* (Generic / Preferred / Non-preferred / Specialty)	$15 / $50 / No charge after ded. / No charge after ded.	$15 / $50 / No charge after ded. / No charge after ded.	$1 / $25 / No charge after ded. / No charge after ded.	$1 / $25 / No charge after ded. / No charge after ded.

Plan Name	Balanced Care 4 (2017) – Standard	Balanced Care 4 (2017) – 73% AV	Balanced Care 4 (2017) – 87% AV	Balanced Care 4 (2017) – 94% AV
Medical Deductible(Ind/Fam)	$7,050/$14,100	$5,250/$10,500	$2,000/$4,000	$600/$1,200
Prescription Drug Deductible(Ind/Fam)	Integrated with medical ded.	Integrated with medical ded.	Integrated with medical ded.	Integrated with medical ded.
Metal Level	Silver	Silver	Silver	Silver
Out-of-pocket Maximum(Ind/Fam)	$7,050/$14,100	$5,250/$10,500	$2,000/$4,000	$600/$1,200
Annual Well Visit/ Preventive Care	No charge	No charge	No charge	No charge
PCP Office Visit	$30	$15	No charge	No charge
Specialist Office Visit	$60	$40	$5	$5
Imaging(CT/PET Scans, MRIs)	No charge after ded.	No charge after ded.	No charge after ded.	No charge after ded.
X-rays & Diagnostic Imaging	No charge after ded.	No charge after ded.	No charge after ded.	No charge after ded.
Urgent Care	$100	$75	$50	$50
Emergency Room*	No charge after ded.	No charge after ded.	No charge after ded.	No charge after ded.
Emergency Transportation*	No charge after ded.	No charge after ded.	No charge after ded.	No charge after ded.
Inpatient Facility Fee	No charge after ded.	No charge after ded.	No charge after ded.	No charge after ded.
Inpatient Hospital Physician & Surgical Services	No charge after ded.	No charge after ded.	No charge after ded.	No charge after ded.
Outpatient Facility Fee	No charge after ded.	No charge after ded.	No charge after ded.	No charge after ded.
Outpatient Surgery Physician/Surgical Services	No charge after ded.	No charge after ded.	No charge after ded.	No charge after ded.
Labs & Diagnostics	No charge after ded.	No charge after ded.	No charge after ded.	No charge after ded.
Mental/Behavioral Health & Substance Use Disorder Outpatient Services	$30	$15	No charge	No charge
Rehabilitation Outpatient Services(Includes Speech, Occupational, Physical Therapy)	No charge after ded.	No charge after ded.	No charge after ded.	No charge after ded.
Skilled Nursing Facility	No charge after ded.	No charge after ded.	No charge after ded.	No charge after ded.
Pediatric Vision- Routine Eye Exam(1 visit per year)	100% Covered	100% Covered	100% Covered	100% Covered
Pediatric Vision- Eyeglasses(frames, 1 per year)	100% Covered	100% Covered	100% Covered	100% Covered
Pedicatric Vision- Lenses(per pair)	100% Covered	100% Covered	100% Covered	100% Covered
Pharmacy* (Generic / Preferred / Non-preferred / Specialty)	$15 / $50 / No charge after ded. / No charge after ded.	$15 / $50 / No charge after ded. / No charge after ded.	No charge / $25 / No charge after ded. / No charge after ded.	No charge / $25 / No charge after ded. / No charge after ded.

Plan Name	Balanced Care 10 (2017) – Standard	Balanced Care 10 (2017) – 73% AV	Balanced Care 10 (2017) – 87% AV	Balanced Care 10 (2017) – 94% AV
Medical Deductible(Ind/Fam)	$4,500/$9,000	$4,000/$8,000	$1,000/$2,000	$250/$500
Prescription Drug Deductible(Ind/Fam)	Integrated with medical ded.	Integrated with medical ded.	Integrated with medical ded.	Integrated with medical ded.
Metal Level	Silver	Silver	Silver	Silver
Out-of-pocket Maximum(Ind/Fam)	$6,500/$13,000	$5,500/$11,000	$1,750/$3,500	$550/$1,100
Annual Well Visit/ Preventive Care	No charge	No charge	No charge	No charge
PCP Office Visit	$20	$10	$1	$1
Specialist Office Visit	$40	$20	$5	$5
Imaging(CT/PET Scans, MRIs)	20% after ded.	20% after ded.	20% after ded.	20% after ded.
X-rays & Diagnostic Imaging	20% after ded.	20% after ded.	20% after ded.	20% after ded.
Urgent Care	$100	$75	$50	$50
Emergency Room*	20% after ded.	20% after ded.	20% after ded.	20% after ded.
Emergency Transportation*	20% after ded.	20% after ded.	20% after ded.	20% after ded.
Inpatient Facility Fee	20% after ded.	20% after ded.	20% after ded.	20% after ded.
Inpatient Hospital Physician & Surgical Services	20% after ded.	20% after ded.	20% after ded.	20% after ded.
Outpatient Facility Fee	20% after ded.	20% after ded.	20% after ded.	20% after ded.
Outpatient Surgery Physician/Surgical Services	20% after ded.	20% after ded.	20% after ded.	20% after ded.
Labs & Diagnostics	20% after ded.	20% after ded.	20% after ded.	20% after ded.
Mental/Behavioral Health & Substance Use Disorder Outpatient Services	$20	$10	$1	$1
Rehabilitation Outpatient Services(Includes Speech, Occupational, Physical Therapy)	20% after ded.	20% after ded.	20% after ded.	20% after ded.
Skilled Nursing Facility	20% after ded.	20% after ded.	20% after ded.	20% after ded.
Pediatric Vision- Routine Eye Exam(1 visit per year)	100% Covered	100% Covered	100% Covered	100% Covered
Pediatric Vision- Eyeglasses(frames, 1 per year)	100% Covered	100% Covered	100% Covered	100% Covered
Pedicatric Vision- Lenses(per pair)	100% Covered	100% Covered	100% Covered	100% Covered
Pharmacy* (Generic / Preferred / Non-preferred / Specialty)	$10 / $50 / 20% after ded. / 20% after ded.	$5 / $50 / 20% after ded. / 20% after ded.	$1 / $25 / 20% after ded. / 20% after ded.	$1 / $25 / 20% after ded. / 20% after ded.

Plan Name	Balanced Care 12 (2017) – Standard	Balanced Care 12 (2017) – 73% AV	Balanced Care 12 (2017) – 87% AV	Balanced Care 12 (2017) – 94% AV
Medical Deductible(Ind/Fam)	$3,500/$7,000	$3,000/$6,000	$700/$1,400	$250/$500
Prescription Drug Deductible(Ind/Fam)	Integrated with medical ded.	Integrated with medical ded.	Integrated with medical ded.	Integrated with medical ded.
Metal Level	Silver	Silver	Silver	Silver
Out-of-pocket Maximum(Ind/Fam)	$7,150/$14,300	$5,700/$11,400	$2,000/$4,000	$1,250/$2,500
Annual Well Visit/ Preventive Care	No charge	No charge	No charge	No charge
PCP Office Visit	$30	$30	$10	$5
Specialist Office Visit	$65	$65	$25	$15
Imaging(CT/PET Scans, MRIs)	20% after ded.	20% after ded.	20% after ded.	5% after ded.
X-rays & Diagnostic Imaging	20% after ded.	20% after ded.	20% after ded.	5% after ded.
Urgent Care	$75	$75	$40	$25
Emergency Room*	$400 after ded.	$300 after ded.	$150 after ded.	$100 after ded.
Emergency Transportation*	20% after ded.	20% after ded.	20% after ded.	5% after ded.
Inpatient Facility Fee	20% after ded.	20% after ded.	20% after ded.	5% after ded.
Inpatient Hospital Physician & Surgical Services	20% after ded.	20% after ded.	20% after ded.	5% after ded.
Outpatient Facility Fee	20% after ded.	20% after ded.	20% after ded.	5% after ded.
Outpatient Surgery Physician/Surgical Services	20% after ded.	20% after ded.	20% after ded.	5% after ded.
Labs & Diagnostics	20% after ded.	20% after ded.	20% after ded.	5% after ded.
Mental/Behavioral Health & Substance Use Disorder Outpatient Services	$30	$30	$10	$5
Rehabilitation Outpatient Services(Includes Speech, Occupational, Physical Therapy)	20% after ded.	20% after ded.	20% after ded.	5% after ded.
Skilled Nursing Facility	20% after ded.	20% after ded.	20% after ded.	5% after ded.
Pediatric Vision- Routine Eye Exam(1 visit per year)	100% Covered	100% Covered	100% Covered	100% Covered
Pediatric Vision- Eyeglasses(frames, 1 per year)	100% Covered	100% Covered	100% Covered	100% Covered
Pedicatric Vision- Lenses(per pair)	100% Covered	100% Covered	100% Covered	100% Covered
Pharmacy* (Generic / Preferred / Non-preferred / Specialty)	$15 / $50 / $100 / 40%	$10 / $50 / $100 / 40%	$5 / $25 / $50 / 30%	$3 / $5 / $10 / 25%