Ambetter Health Solutions Silver Copay HSA 4000 + Vision + Adult Dental

Health Insurance Plan Details (2026 Plan)

EPO

HSA

Silver

Deductible (per individual)	$4,000 /yr
Deductible (per family)	$8,000 /yr
Max Out-of-Pocket (per individual)	$7,000 /yr
Max Out-of-Pocket (per family)	$14,000 /yr
Plan Type	EPO
Includes Child Dental?	No
Includes Adult Dental?	Yes

Medical Services
Preventive Care	No Charge
Primary Care Visit	$25 Copay after deductible
Specialist Visit	$50 Copay after deductible
Emergency Room	30.00% Coinsurance after deductible
Inpatient Facility	30.00% Coinsurance after deductible
Inpatient Physician	30.00% Coinsurance after deductible

Drug Costs
Generic Drugs	$3 Copay after deductible
Preferred Brand Drugs	$60 Copay after deductible
Non-preferred Brand Drugs	45.00% Coinsurance after deductible
Specialty Drugs	50.00% Coinsurance after deductible

Summary of Benefits and Coverage	SBC doc
Provider Directory	Doctor lookup
Drug Formulary List	n/a

* 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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