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Ambetter from PA Health and Wellness - Ambetter Secure Care 20
Benefits Resources
Provider Directory
Summary of Benefits and Coverage
Download Plan Brochure
Drug List
Summary
Plan Type
HMO
HSA-compatible
No
Overall Quality Rating
Not Available
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
$35 Copay
100% Coinsurance
Specialist Visit
$55 Copay
100% Coinsurance
Other Practitioner Office Visit (Nurse, Physician Assistant)
$35 Copay
100% Coinsurance
Preventive Care/Screening/Immunization
No Charge
100% Coinsurance
Tests
In Network
Out-of-Network
Additional Information
Laboratory Outpatient and Professional Services
$35 Copay
100% Coinsurance
X-rays and Diagnostic Imaging
35% Coinsurance after deductible
100% Coinsurance
Imaging (CT/PET scans, MRIs)
35% Coinsurance after deductible
100% Coinsurance
Drugs
In Network
Out-of-Network
Additional Information
Generic Drugs
$13.80 Copay
100% Coinsurance
Preferred Brand Drugs
$60 Copay
100% Coinsurance
Non-Preferred Brand Drugs
50% Coinsurance after deductible
100% Coinsurance
Specialty drugs
50% Coinsurance after deductible
100% Coinsurance
Outpatient
In Network
Out-of-Network
Additional Information
Outpatient Facility Fee
35% Coinsurance after deductible
100% Coinsurance
Outpatient Surgery Physician/Surgical Services
35% Coinsurance after deductible
100% Coinsurance
Urgent Care
In Network
Out-of-Network
Additional Information
Emergency Room Services
35% Coinsurance after deductible
35% Coinsurance after deductible
Emergency Transportation/Ambulance
35% Coinsurance after deductible
35% Coinsurance after deductible
Urgent Care
$35 Copay
100% Coinsurance
Hospital
In Network
Out-of-Network
Additional Information
Inpatient Hospital Services
35% Coinsurance after deductible
100% Coinsurance
Inpatient Physician and Surgical Services
35% Coinsurance after deductible
100% Coinsurance
Mental / Behavioral Health
In Network
Out-of-Network
Additional Information
Mental/Behavioral Health Outpatient Services
$35 Copay
100% Coinsurance
Mental/Behavioral Health Inpatient Services
35% Coinsurance after deductible
100% Coinsurance
Substance Abuse Disorder Outpatient Services
$35 Copay
100% Coinsurance
Substance Abuse Disorder Inpatient Services
35% Coinsurance after deductible
100% Coinsurance
Pregnancy
In Network
Out-of-Network
Additional Information
Prenatal and postnatal care
$35 Copay
100% Coinsurance
Delivery and All Inpatient Services for Maternity Care
35% Coinsurance after deductible
100% Coinsurance
Other Special Needs
In Network
Out-of-Network
Additional Information
Home Healthcare Services
35% Coinsurance after deductible
100% Coinsurance
Outpatient Rehabilitation Services
35% Coinsurance after deductible
100% Coinsurance
Habilitation Services
35% Coinsurance after deductible
100% Coinsurance
Skilled Nursing Facility
35% Coinsurance after deductible
100% Coinsurance
Durable Medical Equipment
35% Coinsurance after deductible
100% Coinsurance
Hospice Services
35% Coinsurance after deductible
100% Coinsurance
Chiropractic Care
$55 Copay
100% Coinsurance
Acupuncture
Not covered
Not covered
Rehabilitative Speech Therapy
35% Coinsurance after deductible
100% Coinsurance
Rehabilitative Occupational and Rehabilitative Physical Therapy
35% Coinsurance after deductible
100% Coinsurance
Well Baby Visits and Care
No Charge
100% Coinsurance
Allergy Testing
$55 Copay
100% Coinsurance
Diabetes Education
$55 Copay
100% Coinsurance
Nutritional Counseling
$55 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
35% 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
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