Ambetter Cascade Select Complete Gold
Coordinated Care Corporation · 2027 plan year
Gold
- Ind. deductible
- $1,700
- Family deductible
- $3,400
- Ind. OOP max
- $7,000
- Family OOP max
- $14,000
Other cost-sharing reduction variants for this plan:
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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 |
Specialist
| Benefit | In-network |
|---|---|
| Specialist Visit | $40.00 |
Hospital
| Benefit | In-network |
|---|---|
| Emergency Room Services | $450.00 Copay after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay) | $525.00 Copay per Day |
| Mental/Behavioral Health Emergency Room | $450.00 Copay after deductible |
| Mental/Behavioral Health Urgent Care | $35.00 |
| Outpatient Surgery Physician/Surgical Services | $75.00 Copay after deductible |
| Substance Use Disorder Emergency Room | $450.00 Copay after deductible |
| Substance Use Disorder Urgent Care | $35.00 |
| Urgent Care Centers or Facilities | $35.00 |
Pharmacy
| Benefit | In-network |
|---|---|
| Generic Drugs | $10.00 |
| Non-Preferred Brand Drugs | $100.00 |
| Preferred Brand Drugs | $60.00 |
| Specialty Drugs | $100.00 |
Mental Health
| Benefit | In-network |
|---|---|
| Mental/Behavioral Health Emergency Transportation/Ambulance | $450.00 Copay after deductible |
| Mental/Behavioral Health ER Physician Fee | No Charge after deductible |
| Mental/Behavioral Health Inpatient Services | $525.00 Copay per Day |
| Mental/Behavioral Health Outpatient Other Services | $15.00 |
| Mental/Behavioral Health Outpatient Services | $15.00 |
| Substance Use Disorder Emergency Transportation/Ambulance | $450.00 Copay after deductible |
| Substance Use Disorder ER Physician Fee | No Charge after deductible |
| Substance Use Disorder Outpatient Other Services | $15.00 |
Other
| Benefit | In-network |
|---|---|
| Abortion for Which Public Funding is Prohibited | No charge |
| Accidental Dental | $350.00 Copay after deductible |
| Acupuncture | $15.00 |
| Allergy Testing | $40.00 |
| Chemotherapy | 20.00% Coinsurance after deductible |
| Chiropractic Care | $15.00 |
| Cosmetic Surgery | $525.00 |
| Delivery and All Inpatient Services for Maternity Care | $525.00 |
| Dental Anesthesia | $350.00 Copay after deductible |
| Diabetes Care Management | No charge |
| Diabetes Education | No charge |
| Dialysis | $350.00 Copay after deductible |
| Durable Medical Equipment | 20.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance | $375.00 |
| Eye Glasses for Children | No charge |
| Gender Affirming Care | $525.00 |
| Habilitation Services | $25.00 |
| Hearing Aids | 20.00% |
| Hearing Exams | $15.00 |
| Home Health Care Services | $15.00 |
| Hospice Services | $15.00 |
| Imaging (CT/PET Scans, MRIs) | $300.00 Copay after deductible |
| Infertility Treatment | $350.00 Copay after deductible |
| Infusion Therapy | $350.00 Copay after deductible |
| Inherited Metabolic Disorder - PKU | $30.00 |
| Inpatient Physician and Surgical Services | No charge |
| Laboratory Outpatient and Professional Services | $30.00 |
| Nutritional Counseling | No charge |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $15.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | $350.00 Copay after deductible |
| Outpatient Rehabilitation Services | $25.00 |
| Prenatal and Postnatal Care | No charge |
| Prosthetic Devices | 20.00% Coinsurance after deductible |
| Radiation | $350.00 Copay after deductible |
| Reconstructive Surgery | $525.00 |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $25.00 |
| Rehabilitative Speech Therapy | $25.00 |
| Routine Eye Exam for Children | No charge |
| Routine Foot Care | $40.00 |
| Skilled Nursing Facility | $350.00 Copay per Day after deductible |
| Substance Abuse Disorder Inpatient Services | $525.00 Copay per Day |
| Substance Abuse Disorder Outpatient Services | $15.00 |
| Transplant | $525.00 |
| Treatment for Temporomandibular Joint Disorders | $350.00 Copay after deductible |
| Well Baby Visits and Care | No charge |
| X-rays and Diagnostic Imaging | $30.00 |
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