Complete Gold

Health Insurance Plan Details (2024 Plan)

by Ambetter Health of Delaware

Monthly Premium

EPO
$ubsidy
Gold
Deductible
$1,450 /yr
Max Out-of-Pocket
$7,500 /yr

Details

Deductible (per individual) $1,450 /yr
Deductible (per family) $2,900 /yr
Max Out-of-Pocket (per individual) $7,500 /yr
Max Out-of-Pocket (per family) $15,000 /yr
Drug Deductible (per individual) Included in Medical
Drug Deductible (per family) Included in Medical
Drug Max Out-of-Pocket (per individual) Included in Medical
Drug Max Out-of-Pocket (per family) Included in Medical
Plan Type EPO
Includes Child Dental? No
Includes Adult Dental? No
Medical Services
Preventive Care No Charge
Primary Care Visit $15 Copay
Specialist Visit $35 Copay
Emergency Room 20% Coinsurance after deductible
Inpatient Facility 20% Coinsurance after deductible
Inpatient Physician 20% Coinsurance after deductible
Drug Costs
Generic Drugs $3 Copay
Preferred Brand Drugs $30 Copay
Non-preferred Brand Drugs 30% Coinsurance after deductible
Specialty Drugs 30% Coinsurance after deductible

Plan Documents

Summary of Benefits and Coverage SBC doc
Provider Directory Doctor lookup
Drug Formulary List drug list

* Figures shown are only for in-network medical costs

** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible


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