Ambetter from PA Health and Wellness - Ambetter Essential Care: $1,500 Medical Deductible
Deductible
Separate Drug Deductible
Out-of-pocket max
Primary Care Visit
$40 Copay
100% Coinsurance
Specialist Visit
$125 Copay
100% Coinsurance
Other Practitioner Office Visit (Nurse, Physician Assistant)
$40 Copay
100% Coinsurance
Preventive Care/Screening/Immunization
No Charge
100% Coinsurance
Laboratory Outpatient and Professional Services
$60 Copay
100% Coinsurance
X-rays and Diagnostic Imaging
50% Coinsurance after deductible
100% Coinsurance
Imaging (CT/PET scans, MRIs)
50% Coinsurance after deductible
100% Coinsurance
Generic Drugs
$31.40 Copay
100% Coinsurance
Preferred Brand Drugs
$195 Copay
100% Coinsurance
Non-Preferred Brand Drugs
$250 Copay after deductible
100% Coinsurance
Specialty drugs
50% Coinsurance after deductible
100% Coinsurance
Outpatient Facility Fee
50% Coinsurance after deductible
100% Coinsurance
Outpatient Surgery Physician/Surgical Services
50% Coinsurance after deductible
100% Coinsurance
Emergency Room Services
$2500 Copay after deductible
$2500 Copay after deductible
Emergency Transportation/Ambulance
50% Coinsurance after deductible
50% Coinsurance after deductible
Urgent Care
$60 Copay
100% Coinsurance
Inpatient Hospital Services
$3000 Copay per day after deductible
100% Coinsurance
Inpatient Physician and Surgical Services
No Charge
100% Coinsurance
Mental/Behavioral Health Outpatient Services
$40 Copay
100% Coinsurance
Mental/Behavioral Health Inpatient Services
$3000 Copay per day after deductible
100% Coinsurance
Substance Abuse Disorder Outpatient Services
$40 Copay
100% Coinsurance
Substance Abuse Disorder Inpatient Services
$3000 Copay per day after deductible
100% Coinsurance
Prenatal and postnatal care
$40 Copay
100% Coinsurance
Delivery and All Inpatient Services for Maternity Care
$3000 Copay after deductible
100% Coinsurance
Home Healthcare Services
50% Coinsurance after deductible
100% Coinsurance
Outpatient Rehabilitation Services
50% Coinsurance after deductible
100% Coinsurance
Habilitation Services
50% Coinsurance after deductible
100% Coinsurance
Skilled Nursing Facility
$3000 Copay per day after deductible
100% Coinsurance
Durable Medical Equipment
50% Coinsurance after deductible
100% Coinsurance
Hospice Services
50% Coinsurance after deductible
100% Coinsurance
Chiropractic Care
$80 Copay
100% Coinsurance
Acupuncture
Not covered
Not covered
Rehabilitative Speech Therapy
50% Coinsurance after deductible
100% Coinsurance
Rehabilitative Occupational and Rehabilitative Physical Therapy
50% Coinsurance after deductible
100% Coinsurance
Well Baby Visits and Care
No Charge
100% Coinsurance
Allergy Testing
$125 Copay
100% Coinsurance
Diabetes Education
$125 Copay
100% Coinsurance
Nutritional Counseling
$125 Copay
100% Coinsurance
Eye Exam for Children
No Charge
100% Coinsurance
Eye Glasses for Children
No Charge
100% Coinsurance
Accidental Dental
50% Coinsurance after deductible
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