Battle Born State Plan Ambetter PCP Referral Required Gold
SilverSummit Healthplan, Inc. · 2027 plan year
Gold
- Ind. deductible
- $1,550
- Family deductible
- $3,100
- Ind. OOP max
- $6,200
- Family OOP max
- $12,400
Compare with other Gold plans in NV
Side by side: deductibles, out-of-pocket limits and copays.
Other cost-sharing reduction variants for this plan:
More SilverSummit Healthplan, Inc. plans in NV
Monthly premiums by age
Rating Area 4
| Age | Individual | Individual + tobacco |
|---|---|---|
| Under 15 | $721 | $721 |
| 21 | $943 | $1,084 |
| 30 | $1,070 | $1,231 |
| 40 | $1,205 | $1,386 |
| 50 | $1,684 | $1,936 |
| 60 | $2,559 | $2,942 |
| 64 and over | $2,828 | $3,252 |
Live premium estimate
Benefits & cost sharing
Primary Care
| Benefit | In-network |
|---|---|
| Preventive Care/Screening/Immunization | No charge |
| Primary Care Visit to Treat an Injury or Illness | $15.00 Copay after deductible |
Specialist
| Benefit | In-network |
|---|---|
| Specialist Visit | $45.00 Copay after deductible |
Hospital
| Benefit | In-network |
|---|---|
| Emergency Room Services | 15.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay) | 15.00% Coinsurance after deductible |
| Mental/Behavioral Health Emergency Room | 15.00% Coinsurance after deductible |
| Mental/Behavioral Health Urgent Care | $15.00 Copay after deductible |
| Outpatient Surgery Physician/Surgical Services | 15.00% Coinsurance after deductible |
| Substance Use Disorder Emergency Room | 15.00% Coinsurance after deductible |
| Substance Use Disorder Urgent Care | $15.00 Copay after deductible |
| Urgent Care Centers or Facilities | $30.00 Copay after deductible |
Pharmacy
| Benefit | In-network |
|---|---|
| Generic Drugs | $10.00 |
| Non-Preferred Brand Drugs | 30.00% Coinsurance after deductible |
| Preferred Brand Drugs | $30.00 |
| Specialty Drugs | 45.00% Coinsurance after deductible |
| Tier 1b Generic Drugs | $10.00 |
Mental Health
| Benefit | In-network |
|---|---|
| Mental/Behavioral Health Emergency Transportation/Ambulance | 15.00% Coinsurance after deductible |
| Mental/Behavioral Health ER Physician Fee | 15.00% Coinsurance after deductible |
| Mental/Behavioral Health Inpatient Services | 15.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Other Services | 15.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services | $15.00 Copay after deductible |
| Substance Use Disorder Emergency Transportation/Ambulance | 15.00% Coinsurance after deductible |
| Substance Use Disorder ER Physician Fee | 15.00% Coinsurance after deductible |
| Substance Use Disorder Outpatient Other Services | 15.00% Coinsurance after deductible |
Other
| Benefit | In-network |
|---|---|
| Accidental Dental | 15.00% Coinsurance after deductible |
| Allergy Testing | $45.00 Copay after deductible |
| Bariatric Surgery | 15.00% Coinsurance after deductible |
| Chemotherapy | 15.00% Coinsurance after deductible |
| Chiropractic Care | 15.00% Coinsurance after deductible |
| Delivery and All Inpatient Services for Maternity Care | 15.00% Coinsurance after deductible |
| Diabetes Education | 15.00% Coinsurance after deductible |
| Dialysis | 15.00% Coinsurance after deductible |
| Durable Medical Equipment | 15.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance | 15.00% Coinsurance after deductible |
| Eye Glasses for Children | No charge |
| Gender Affirming Care | 15.00% Coinsurance after deductible |
| Habilitation Services | 15.00% Coinsurance after deductible |
| Hearing Aids | 15.00% Coinsurance after deductible |
| Home Health Care Services | 15.00% Coinsurance after deductible |
| Hospice Services | 15.00% Coinsurance after deductible |
| Imaging (CT/PET Scans, MRIs) | 15.00% Coinsurance after deductible |
| Infertility Treatment | 15.00% Coinsurance after deductible |
| Infusion Therapy | 15.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services | 15.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services | $15.00 Copay after deductible |
| Nutritional Counseling | $45.00 Copay after deductible |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $15.00 Copay after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | 15.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services | 15.00% Coinsurance after deductible |
| Prenatal and Postnatal Care | $15.00 Copay after deductible |
| Private-Duty Nursing | 15.00% Coinsurance after deductible |
| Prosthetic Devices | 15.00% Coinsurance after deductible |
| Radiation | 15.00% Coinsurance after deductible |
| Reconstructive Surgery | 15.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | 15.00% Coinsurance after deductible |
| Rehabilitative Speech Therapy | 15.00% Coinsurance after deductible |
| Routine Eye Exam for Children | No charge |
| Routine Foot Care | $45.00 Copay after deductible |
| Skilled Nursing Facility | 15.00% Coinsurance after deductible |
| Substance Abuse Disorder Inpatient Services | 15.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services | $15.00 Copay after deductible |
| Transplant | 15.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders | 15.00% Coinsurance after deductible |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | 15.00% Coinsurance after deductible |
Service area
This plan covers 10 geographic areas.
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