Focused Silver + Vision + Adult Dental

77264NC0020039
Silver
HMO

Focused Silver + Vision + Adult Dental is a Silver HMO plan by Ambetter of North Carolina.

IMPORTANT: You are viewing the 2023 version of Focused Silver + Vision + Adult Dental 77264NC0020039. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Focused Silver + Vision + Adult Dental is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Focused Silver + Vision + Adult Dental 77264NC0020039.
Insurer: Ambetter of North Carolina
Network Type: HMO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 77264NC0020039

Cost-Sharing Overview

Focused Silver + Vision + Adult Dental offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Focused Silver + Vision + Adult Dental?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

Focused Silver + Vision + Adult Dental offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Diabetes, Pregnancy
Notice Pregnancy: Yes
Referral Specialist: No
Specialist Requiring Referral:
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Focused Silver + Vision + Adult Dental covers when you are out of the service area or out of the country.

Out of Country Coverage: No
Out of Country Coverage Description:
Out of Service Area Coverage: No
Out of Service Area Coverage Description:
National Network: No

Additional Benefits and Cost-Sharing

Focused Silver + Vision + Adult Dental includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$45.00 100.00% Unlimited Virtual Care Visits received from Ambetter Telehealth covered at No Charge, except for HSAs.
Specialist Visit
Covered
$100.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$45.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
50.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
50.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
50.00% Coinsurance after deductible 100.00% Benefits for Hospice services for care of a terminally ill Member with a life expectancy of six months or less.
Routine Dental Services (Adult)
Covered
No Charge 100.00%1000 Dollars per Year $1000 annual benefit maximum includes all Dental services(Routine, Basic and Major) for Adults
Infertility Treatment
Covered
50.00% Coinsurance after deductible 100.00%3 Treatment(s) per Lifetime Infertility Services- Benefits are provided for certain services related to the diagnosis, treatment and correction of any underlying causes of infertility for all members. Benefits are limited to three medical ovulation induction cycles per lifetime per member. Prescription Drug Benefits- Certain prescription drugs related to treatment of infertility. Infertility drugs are limited to benefit lifetime maximums per member.
Long-Term/Custodial Nursing Home Care
Not Covered
Long Term Acute Care is a covered benefit. Long Term Nursing Care/ Custodial Care is not a covered benefit.
Private-Duty Nursing
Covered
50.00% Coinsurance after deductible 100.00%
Routine Eye Exam (Adult)
Not Covered
Urgent Care Centers or Facilities
Covered
$60.00 100.00%
Home Health Care Services
Covered
50.00% Coinsurance after deductible 100.00%
Emergency Room Services
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible Note: Prior authorization is not required for emergency transport, however, all non-emergent transport requires prior authorization.
Emergency Transportation/Ambulance
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
50.00% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
50.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Covered
50.00% Coinsurance after deductible 100.00% Medically necessary for the treatment of diseases and ailments
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
50.00% Coinsurance after deductible 100.00%60 Days per Year
Prenatal and Postnatal Care
Covered
$45.00 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
50.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$45.00 100.00%
Mental/Behavioral Health Inpatient Services
Covered
50.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$45.00 100.00%
Substance Abuse Disorder Inpatient Services
Covered
50.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$22.60 100.00% Most Ambetter Plans offer Preferred Generic Drugs at $5 or less. Please see plan’s Summary of Benefits and Coverage (SBC) or policy document for Preferred Generic and Generic prescription drug cost.
Preferred Brand Drugs
Covered
$75.00 100.00%
Non-Preferred Brand Drugs
Covered
50.00% Coinsurance after deductible 100.00%
Specialty Drugs
Covered
50.00% Coinsurance after deductible 100.00%
Outpatient Rehabilitation Services
Covered
50.00% Coinsurance after deductible 100.00%30 Visit(s) per Year Limited to 30 visits per year for outpatient speech therapy; limited to a combined 30 visits per year for outpatient occupational therapy, physical therapy and chiropractic care.
Habilitation Services
Covered
50.00% Coinsurance after deductible 100.00%30 Visit(s) per Year Limited to 30 visits per year for outpatient speech therapy; limited to a combined 30 visits per year for outpatient occupational therapy, physical therapy and chiropractic care.
Chiropractic Care
Covered
$90.00 100.00%30 Visit(s) per Year Limited to a combined 30 visits per year for outpatient occupational therapy, physical therapy and chiropractic care.
Durable Medical Equipment
Covered
50.00% Coinsurance after deductible 100.00% Orthotic devices for correction of POSITIONAL PLAGIOCEPHALY are limited to 1 device per lifetime.
Hearing Aids
Covered
50.00% Coinsurance after deductible 100.00%2 Item(s) per 3 Years One hearing aid per hearing impaired ear, and replacement hearing aids once every 36 months.
Imaging (CT/PET Scans, MRIs)
Covered
50.00% Coinsurance after deductible 100.00% Cost share is based on place of service.
Preventive Care/Screening/Immunization
Covered
No Charge 100.00% Covered in accordance with ACA guidelines.
Routine Foot Care
Not Covered
Coverage is limited to diabetes care only.
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge 100.00%1 Visit(s) per Year
Eye Glasses for Children
Covered
No Charge 100.00%1 Item(s) per Year
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
50.00% Coinsurance after deductible 100.00%30 Visit(s) per Year
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
50.00% Coinsurance after deductible 100.00%30 Visit(s) per Year Limited to 30 visits per year for outpatient speech therapy; limited to a combined 30 visits per year for outpatient occupational therapy, physical therapy and chiropractic care.
Well Baby Visits and Care
Covered
No Charge 100.00% Covered in accordance with ACA guidelines.
Laboratory Outpatient and Professional Services
Covered
$50.00 100.00% Cost share is based on place of service.
X-rays and Diagnostic Imaging
Covered
50.00% Coinsurance after deductible 100.00% Cost share is based on place of service.
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Covered
50.00% 100.00%1000 Dollars per Year $1000 annual benefit maximum includes all Dental services(Routine, Basic and Major) for Adults
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Covered
50.00% 100.00%1000 Dollars per Year $1000 annual benefit maximum includes all Dental services(Routine, Basic and Major) for Adults
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
50.00% Coinsurance after deductible 100.00% Both the recipient and the donor are entitled to benefits of this coverage when the recipient is a MEMBER. Benefits provided to the donor will be charged against the recipient’s coverage.
Accidental Dental
Covered
50.00% Coinsurance after deductible 100.00%
Dialysis
Covered
50.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
$100.00 100.00%
Chemotherapy
Covered
50.00% Coinsurance after deductible 100.00%
Radiation
Covered
50.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
$100.00 100.00%
Prosthetic Devices
Covered
50.00% Coinsurance after deductible 100.00%
Infusion Therapy
Covered
50.00% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
50.00% Coinsurance after deductible 100.00%
Nutritional Counseling
Covered
$100.00 100.00% Nutritional counseling visits are separate from the obesity-related office visits.
Reconstructive Surgery
Covered
50.00% Coinsurance after deductible 100.00%
Gender Affirming Care
Covered
50.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Outpatient Other Services
Covered
50.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Other Services
Covered
50.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Emergency Room
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Substance Use Disorder Emergency Room
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Mental/Behavioral Health ER Physician Fee
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Substance Use Disorder ER Physician Fee
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Mental/Behavioral Health Emergency Transportation/Ambulance
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Substance Use Disorder Emergency Transportation/Ambulance
Covered
50.00% Coinsurance after deductible 50.00% Coinsurance after deductible
Mental/Behavioral Health Urgent Care
Covered
$60.00 100.00%
Substance Use Disorder Urgent Care
Covered
$60.00 100.00%

Free Preventive Services

There is no copayment or coinsurance for any of the following Focused Silver + Vision + Adult Dental preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for Focused Silver + Vision + Adult Dental including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for Focused Silver + Vision + Adult Dental?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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