Signature Gold with Atrium Health + Vision + Adult Dental
Ambetter of North Carolina · 2027 plan year
Gold
- Ind. deductible
- $2,500
- Family deductible
- $5,000
- Ind. OOP max
- $8,600
- Family OOP max
- $17,200
Compare with other Gold plans in NC
Side by side: deductibles, out-of-pocket limits and copays.
Other cost-sharing reduction variants for this plan:
Monthly premiums by age
Rating Area 7 — the lowest-priced of the 4 areas this plan covers. Premiums differ by area.
| Age | Individual | Individual + tobacco |
|---|---|---|
| Under 15 | $384 | $384 |
| 21 | $502 | $577 |
| 30 | $570 | $655 |
| 40 | $641 | $738 |
| 50 | $896 | $1,031 |
| 60 | $1,362 | $1,566 |
| 64 and over | $1,505 | $1,731 |
Live premium estimate
Benefits & cost sharing
Primary Care
| Benefit | In-network |
|---|---|
| Primary Care Visit to Treat an Injury or Illness | $30.00 |
| Preventive Care/Screening/Immunization | No charge |
Specialist
| Benefit | In-network |
|---|---|
| Specialist Visit | $60.00 |
Hospital
| Benefit | In-network |
|---|---|
| Emergency Room Services | 25.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay) | 25.00% Coinsurance after deductible |
| Mental/Behavioral Health Emergency Room | 25.00% Coinsurance after deductible |
| Mental/Behavioral Health Urgent Care | $30.00 |
| Outpatient Surgery Physician/Surgical Services | 25.00% Coinsurance after deductible |
| Substance Use Disorder Emergency Room | 25.00% Coinsurance after deductible |
| Substance Use Disorder Urgent Care | $30.00 |
| Urgent Care Centers or Facilities | $45.00 |
Pharmacy
| Benefit | In-network |
|---|---|
| Generic Drugs | $15.00 |
| Non-Preferred Brand Drugs | $60.00 |
| Preferred Brand Drugs | $30.00 |
| Specialty Drugs | $250.00 |
Mental Health
| Benefit | In-network |
|---|---|
| Mental/Behavioral Health Emergency Transportation/Ambulance | 25.00% Coinsurance after deductible |
| Mental/Behavioral Health ER Physician Fee | 25.00% Coinsurance after deductible |
| Mental/Behavioral Health Inpatient Services | 25.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Other Services | No charge |
| Mental/Behavioral Health Outpatient Services | $30.00 |
| Substance Use Disorder Emergency Transportation/Ambulance | 25.00% Coinsurance after deductible |
| Substance Use Disorder ER Physician Fee | 25.00% Coinsurance after deductible |
| Substance Use Disorder Outpatient Other Services | No charge |
Other
| Benefit | In-network |
|---|---|
| Imaging (CT/PET Scans, MRIs) | 25.00% Coinsurance after deductible |
| Private-Duty Nursing | 25.00% Coinsurance after deductible |
| Prosthetic Devices | 25.00% Coinsurance after deductible |
| Radiation | 25.00% Coinsurance after deductible |
| X-rays and Diagnostic Imaging | 25.00% Coinsurance after deductible |
| Abortion for Which Public Funding is Prohibited | Not covered |
| Accidental Dental | 25.00% Coinsurance after deductible |
| Acupuncture | Not covered |
| Allergy Testing | $60.00 |
| Bariatric Surgery | 25.00% Coinsurance after deductible |
| Basic Dental Care - Adult | 50.00% |
| Basic Dental Care - Child | Not covered |
| Chemotherapy | 25.00% Coinsurance after deductible |
| Chiropractic Care | $60.00 |
| Cosmetic Surgery | Not covered |
| Delivery and All Inpatient Services for Maternity Care | 25.00% Coinsurance after deductible |
| Dental Check-Up for Children | Not covered |
| Diabetes Education | $60.00 |
| Dialysis | 25.00% Coinsurance after deductible |
| Durable Medical Equipment | 25.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance | 25.00% Coinsurance after deductible |
| Eye Glasses for Children | No charge |
| Habilitation Services | $30.00 |
| Hearing Aids | 25.00% Coinsurance after deductible |
| Home Health Care Services | 25.00% Coinsurance after deductible |
| Hospice Services | 25.00% Coinsurance after deductible |
| Infertility Treatment | 25.00% Coinsurance after deductible |
| Infusion Therapy | 25.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services | 25.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services | 25.00% Coinsurance after deductible |
| Long-Term/Custodial Nursing Home Care | Not covered |
| Major Dental Care - Adult | 50.00% |
| Major Dental Care - Child | Not covered |
| Nutritional Counseling | $60.00 |
| Orthodontia - Adult | Not covered |
| Orthodontia - Child | Not covered |
| Other Practitioner Office Visit (Nurse, Physician Assistant) | $30.00 |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | 25.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services | $30.00 |
| Prenatal and Postnatal Care | $30.00 |
| Reconstructive Surgery | 25.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy | $30.00 |
| Rehabilitative Speech Therapy | $30.00 |
| Routine Dental Services (Adult) | No charge |
| Routine Eye Exam (Adult) | No charge |
| Routine Eye Exam for Children | No charge |
| Routine Foot Care | $60.00 |
| Skilled Nursing Facility | 25.00% Coinsurance after deductible |
| Substance Abuse Disorder Inpatient Services | 25.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services | $30.00 |
| Transplant | 25.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders | 25.00% Coinsurance after deductible |
| Weight Loss Programs | Not covered |
| Well Baby Visits and Care | No charge |
Plan rules
Service area
This plan covers 16 geographic areas.
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