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Ambetter Health Solutions Silver HSA 4000 + Vision + Adult Dental
Plan Summary
Plan Type EPO
Office Visit for Primary Doctor
Find Doctors 		20% Coinsurance after deductible
Office Visit for Specialist 20% Coinsurance after deductible
Office Visit for Other Practitioner (Nurse, Physician Assistant) 20% Coinsurance after deductible
Annual Deductible Individual: $4,000
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Coinsurance 20%
Retail Prescription Drugs Generic Drugs: 20% Coinsurance after deductible;
Preferred Brand Drugs: 20% Coinsurance after deductible;
Non-Preferred Brand Drugs: 20% Coinsurance after deductible;
Specialty Drugs: 50% Coinsurance after deductible;
Off Label Prescription Drugs: 50% Coinsurance after deductible;
Annual Out-of-Pocket Limit Individual: $7,000
Includes deductible
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage No 
Out-of-Country Coverage No.
Office Visit
Primary Care Physician Required Yes
Specialist Referrals Required No
Preventive Care Coverage
Periodic Health Exam No Charge
Periodic OB-GYN Exam No Charge
Well Baby Care No Charge
Emergency and Urgent Care
Emergency Room 20% Coinsurance after deductible
Emergency Ambulance Services 20% Coinsurance after deductible
Urgent Care Facility 20% Coinsurance after deductible
Prescription Drug Coverage
Retail Prescription Drugs Generic Drugs: 20% Coinsurance after deductible;
Preferred Brand Drugs: 20% Coinsurance after deductible;
Non-Preferred Brand Drugs: 20% Coinsurance after deductible;
Specialty Drugs: 50% Coinsurance after deductible;
Off Label Prescription Drugs: 50% Coinsurance after deductible;
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Mail Order Prescription Drugs N/A
Mail Order Supply N/A
Outpatient Coverage
Outpatient Surgery Outpatient Surgery Physician/Surgical Services:
20% Coinsurance after deductible
Outpatient Facility Fee:
20% Coinsurance after deductible
Outpatient Lab/X-Ray Outpatient Lab:
20% Coinsurance after deductible
X-rays:
20% Coinsurance after deductible
Imaging (CT and PET scans, MRIs) 20% Coinsurance after deductible
Outpatient Mental Health 20% Coinsurance after deductible
Outpatient Substance Abuse 20% Coinsurance after deductible
Outpatient Rehabilitation Services (PT, OT, ST) 20% Coinsurance after deductible, limited to 20 Visit(s) per Year
Inpatient Coverage
Hospitalization Inpatient Hospital Services:
20% Coinsurance after deductible
Inpatient Physician and Surgical Services:
20% Coinsurance after deductible
Skilled Nursing Facility 20% Coinsurance after deductible, limited to 60 Days per Year
Inpatient Mental Health 20% Coinsurance after deductible
Inpatient Substance Abuse 20% Coinsurance after deductible
Home Healthcare 20% Coinsurance after deductible
Maternity Coverage
Pre & Postnatal Office Visit 20% Coinsurance after deductible
Labor & Delivery Hospital Stay 20% Coinsurance after deductible
Pediatric Services
Dental Checkup for Children Not Covered
Vision Screening for Children No Charge, limited to 1 Exam(s) per Year
Eye Glasses for Children No Charge, limited to 1 Item(s) per Year
Major Dental Coverage (Pediatric) Not Covered
Additional Coverage
Chiropractic Coverage 20% Coinsurance after deductible, limited to 20 Visit(s) per Year
Durable Medical Equipment 20% Coinsurance after deductible
Hospice 20% Coinsurance after deductible
Major Dental Coverage (Adult) 50% Coinsurance, limited to 1000 Dollars per Year
Vision Coverage (Adult) No Charge, limited to 1 Exam(s) per Year
Out-of-Network Coverage
Out-of-Network Authorization Required N/A
Out-of-Network Annual Deductible N/A
Out-of-Network Annual Coinsurance N/A
Out-of-Network Annual Out-of-Pocket Limit N/A
Additional Information
A.M. Best Rating N/A as of 03/09/2025
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure Exclusions and Limitations

Important notices and disclaimers

  • The information shown here is a summary of benefits for informational purposes only. Review the official plan documents (such as evidence of coverage, plan brochure, or insurance policy) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
  • The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
  • The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
  • Each insurance carrier may have unique Notices, Disclaimers, and Fees. Please check below for information regarding the plans and carriers you selected.
  • The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
  • The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.