Ambetter Balanced Care 5 + Vision + Adult Dental (2020)
| Plan Type: | EPO |
| Plan Tier: | Silver |
| Medical Deductible - Individual: | $7350 |
| Medical Deductible - Family: | Included in Medical |
| Drug Deductible - Individual: | $7350 |
| Drug Deductible - Family: | Included in Medical |
| Out of Pocket Max - Individual: | $7350 |
| Out of Pocket Max - Family: | $7350 |
| Primary Care Visit: | $40 |
| Specialist Visit: | $80 |
| Emergency Room: | No Charge after Deductible |
| Hospital - Physician: | No Charge after Deductible |
| Hospital - Facility: | No Charge after Deductible |
| Link to Full SBC: | https://api.centene.com/SBC/2020/21663FL0150027-01.pdf |
| Plan Brochure: | https://api.centene.com/Brochures/2020/21663FL0150027-01.pdf |
Other Coverage:
| Child Dental: | No |
| Adult Dental | Yes |
Prescription Drug Pricing:
| Generic Drugs: | $20 |
| Non-Preferred Brand Drugs: | No Charge after Deductible |
| Preferred Brand Drugs: | $60 |
| Specialty Drugs: | No Charge after Deductible |
| Link to Full Policy Formulary: | https://ambetter.sunshinehealth.com/resources/pharmacy-resources.html |
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