Ambetter Virtual Access Bronze ($0 Virtual PCP, Urgent Care, & Labs Via Ambetter-Designated Providers; Virtual PCP Required) – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$7,000 per person $7,000 per person
Out-of-pocket max	$8,550 per person $17,100 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	$65 copay
Specialist visit	$100 copay after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$60 copay
Emergency room	50% coinsurance after deductible
Ambulance	50% coinsurance after deductible
Hospital stay (facility)	50% coinsurance after deductible
Hospital stay (physician)	50% coinsurance after deductible
Outpatient procedure (facility)	50% coinsurance after deductible
Outpatient procedure (physician)	50% coinsurance after deductible
Physical rehabilitation	50% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	50% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$3 copay
Brand	$160 copay after deductible
Non-preferred Brand	50% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	50% coinsurance after deductible
Imaging (CT/PET/MRI)	50% coinsurance after deductible
Blood work	$75 copay

Mental and Psychiatric Health Care

Mental Health outpatient services	No charge
Psychiatric hospital stay	50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://api.centene.com/SBC/2024/77264NC0060001-01.pdf
Drug and medication plan formulary	https://ambetterofnorthcarolina.com/resources/pharmacy-resources.html
Search doctor list	https://ambetterofnorthcarolina.com/findadoc