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Ambetter from SilverSummit   -   Focused Silver

Deductible & Out-of-Pocket
In Network
Out-of-Network
Deductible
Out-of-pocket max
Doctor Visit
In Network
Out-of-Network
Additional Information
Primary Care Visit
No Charge
100% Coinsurance
Specialist Visit
$15 Copay
100% Coinsurance
Other Practitioner Office Visit (Nurse, Physician Assistant)
No Charge
100% Coinsurance
Preventive Care/Screening/Immunization
No Charge
100% Coinsurance
Tests
In Network
Out-of-Network
Additional Information
Laboratory Outpatient and Professional Services
No Charge
100% Coinsurance
X-rays and Diagnostic Imaging
30% Coinsurance
100% Coinsurance
Imaging (CT/PET scans, MRIs)
30% Coinsurance
100% Coinsurance
Drugs
In Network
Out-of-Network
Additional Information
Generic Drugs
No Charge
100% Coinsurance
Preferred Brand Drugs
$25 Copay
100% Coinsurance
Non-Preferred Brand Drugs
45% Coinsurance
100% Coinsurance
Specialty drugs
50% Coinsurance
100% Coinsurance
Outpatient
In Network
Out-of-Network
Additional Information
Outpatient Facility Fee
30% Coinsurance
100% Coinsurance
Outpatient Surgery Physician/Surgical Services
30% Coinsurance
100% Coinsurance
Urgent Care
In Network
Out-of-Network
Additional Information
Emergency Room Services
30% Coinsurance
30% Coinsurance
Emergency Transportation/Ambulance
30% Coinsurance
30% Coinsurance
Urgent Care
$10 Copay
100% Coinsurance
Hospital
In Network
Out-of-Network
Additional Information
Inpatient Hospital Services
30% Coinsurance
100% Coinsurance
Inpatient Physician and Surgical Services
30% Coinsurance
100% Coinsurance
Mental / Behavioral Health
In Network
Out-of-Network
Additional Information
Mental/Behavioral Health Outpatient Services
No Charge
100% Coinsurance
Mental/Behavioral Health Inpatient Services
30% Coinsurance
100% Coinsurance
Substance Abuse Disorder Outpatient Services
No Charge
100% Coinsurance
Substance Abuse Disorder Inpatient Services
30% Coinsurance
100% Coinsurance
Pregnancy
In Network
Out-of-Network
Additional Information
Prenatal and postnatal care
No Charge
100% Coinsurance
Delivery and All Inpatient Services for Maternity Care
30% Coinsurance
100% Coinsurance
Other Special Needs
In Network
Out-of-Network
Additional Information
Home Healthcare Services
30% Coinsurance
100% Coinsurance
Outpatient Rehabilitation Services
30% Coinsurance
100% Coinsurance
Habilitation Services
30% Coinsurance
100% Coinsurance
Skilled Nursing Facility
30% Coinsurance
100% Coinsurance
Durable Medical Equipment
30% Coinsurance
100% Coinsurance
Hospice Services
30% Coinsurance
100% Coinsurance
Chiropractic Care
$15 Copay
100% Coinsurance
Acupuncture
Not Covered
Not Covered
Rehabilitative Speech Therapy
30% Coinsurance
100% Coinsurance
Rehabilitative Occupational and Rehabilitative Physical Therapy
30% Coinsurance
100% Coinsurance
Well Baby Visits and Care
No Charge
100% Coinsurance
Allergy Testing
$15 Copay
100% Coinsurance
Diabetes Education
$15 Copay
100% Coinsurance
Nutritional Counseling
$15 Copay
100% Coinsurance
Children's Vision
In Network
Out-of-Network
Additional Information
Eye Exam for Children
No Charge
100% Coinsurance
Eye Glasses for Children
No Charge
100% Coinsurance
Dental
In Network
Out-of-Network
Additional Information
Accidental Dental
30% Coinsurance
100% Coinsurance
Basic Dental Care (Adult)
Not Covered
Not Covered
Basic Dental Care (Child)
Not Covered
Not Covered
Dental Check Up (Child)
Not Covered
Not Covered
Major Dental Care (Adult)
Not Covered
Not Covered
Major Dental Care (Child)
Not Covered
Not Covered
Orthodontia (Adult)
Not Covered
Not Covered
Orthodontia (Child)
Not Covered
Not Covered
Routine Dental Services (Adult)
Not Covered
Not Covered

Carrier Notices

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