Ambetter Health Plans Texas

Plan Overviews

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Ambetter Superior Health Plans is the Health Insurance Marketplace (HIM) option operated by CeltiCare, a subsidiary of the Centene Corporation. AmBetter offers lower premiums in bronze, silver and gold coverage categories with a full-price (unsubsidized) premium compared to BCBS of Texas. But the real savings is with the Silver plans, with AmBetter’s cheapest plan carrying a monthly premium 30% lower than a comparable BlueCross BlueShield Texas plan. Ambetter offers only HMO plans or Exclusive Provider Organization (EPO) plans on the exchange. No PPO plans are currently available in the Texas individual marketplace Ambetter has been selling policies on the ACA exchange in Texas since it opened in 2014 has a significant presence in Texas — including Austin, San Antonio and El Paso among other regions. It added 12 counties for 2017 including Tarrant, Denton, Dallas and Rockwall.

The Good

  • Member resources
  • Unique features
  • My Health Pays
  • Dental and vision

Member Resources

Ambetter members are given access to an online portal, through which they can make all their payments, view their plan benefits, and take care of logistics like obtaining a member ID card. The member portal offers extra features too, such as providing reminders for members when they are due for another doctor’s visit or allowing them to take a health risk assessment to determine which steps they can take to live healthier. There’s also a section for member news alerts and, of course, social media accounts with Ambetter that members can connect to. If you’re looking to get an Ambetter plan, you can view their health plans by first selecting the state you live in and then selecting a metal type for the plan tier you’re most interested in. From there, your options open up to several different plans with varying prices and benefits. Members can track their claims 24/7 through the online portal, as well as connect with member services or a nurse hotline at any hour of the day. The subsidy estimator in the online account also helps members see how much they would receive for reimbursement for a treatment with their benefits. Admittedly, many of the resources available to members do not extend far beyond the basic ones supplied by other health insurance companies. Nonetheless, Ambetter’s online portal and customer service mediums do make members’ experience more convenient and secure.

Unique Features

Ambetter provides more than just logistical tools for members. Many of the extra features they offer also send the message that they want their members to get healthier and stay healthier. These tools include a 24/7 nurse hotline that members can access for questions and medical needs. There are also health-promoting programs such as the StartSmart for Your Baby program, which provides support for expecting mothers. Ambetter has support for members coping with behavioral health issues, chronic illnesses, and similar struggles as well. My Health Pays is a rewards program offered by Ambetter, and through it members can be reimbursed for gym memberships and even earn back money for getting a wellness exam or a flu shot. This money can then be used toward a copay or monthly premium down the road.

My Health Pays

My Health Pays is Ambetter’s rewards program to provide incentives for members to live healthier with better habits. You can earn money for taking a survey provided by Ambetter, getting a flu shot, or having your wellness exam, and this money can go toward your next premium.

24/7 Nurse Line

Customers have 24/7 access to a nurse and can contact this healthcare professional for sudden medical concerns and other questions. Round-the-clock support like this adds reassurance to members’ experience.

Dental and Vision

Dental and vision coverage are available with Ambetter, but the benefits and availability of each are entirely specific to the state you live in and the type of plan you’ve signed up for. Dental coverage, for example, is not available in Texas, but vision insurance is. Dental coverage includes exams, cleanings, and screenings, overall, and vision benefits include yearly eye exams and glasses or contacts.

The Bad

  • Types of plans offered (HMO, EPO – no PPO or HSA plans)
  • Service areas
  • Service areas
  • Access to plan information

Types of Plans Offered

It’s somewhat difficult to access specific information about the types of health plans Ambetter has. Their website primarily just explains the metal tiers for their plans, as well as how essential health benefits are covered by every plan. But to find out what kinds of plans these are (such as HMO, PPO, etc.), not to mention what prices and benefits you qualify for, you’ll have to contact a representative. Up front, it’s important to know that Ambetter is part of the Health Insurance Marketplace (HIM). It’s Centene’s option for HIM plans, which is intended for people who don’t have health insurance and maybe don’t qualify for typical plans. In HIM territory, Medicare isn’t an option, for example, because if you qualify for Medicare, that’s the legal option for you to get rather than taking advantage of a plan like Ambetter’s. Medicaid and CHIP are HIM plans, though. Ambetter has PPOs, HMOs, and EPOs. They don’t offer HSAs though. They’ve divided their plans into three metal tiers: Bronze, Silver, and Gold. All three of these tiers cover “essential health benefits,” Ambetter’s term for services like preventative and emergency care, therapy, behavioral health help, medications, maternity, and hospitalization. But the difference in the tiers comes in the costs for premiums and out-of-pocket expenses. Bronze plans have the lowest premiums but the highest OOP costs, and Gold has the highest premiums but the lowest OOP costs. Silver, of course, is the in the middle.

Service Areas

Ambetter plans are available in a select few states. These are Arkansas, Florida, Georgia, Mississippi, Illinois, Indiana, Massachusetts, New Hampshire, Ohio, Texas, Washington, and Wisconsin. If you don’t live in any of these states, then obviously Ambetter isn’t an option for you.

No Mobile App

Unlike many of its competitors, Ambetter doesn’t have a mobile app. Some companies provide this for members to access their accounts right from their phones, making communication and logistics much easier. Ambetter hasn’t provided this yet, making account management slightly less convenient than with other companies.

Access to Plan Information

Ultimately, it’s kind of hard to find specific information about the health plans at Ambetter. The company doesn’t provide enough assistance with truly understanding HIM plans, knowing which types are available up front, and comparing the costs of these plans in one place.

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Plan Name Essential Care 1 (2016) – Standard Essential Care 5 (2016) with 3 Free PCP Visits – Standard
Medical Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. (Ind/Fam) $6,800/$13,600 $6,800/$13,600
Prescription Drug Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. (Ind/Fam) Integrated with medical ded. Integrated with medical ded.
Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services (Ind/Fam) $6,800/$13,600 $6,800/$13,600
Annual Well Visit/ Preventive Care No charge No charge
PCP Office Visit No charge after ded. No charge after ded.
Specialist Office Visit No charge after ded. No charge after ded.
Imaging (CT/PET Scans, MRIs) No charge after ded. No charge after ded.
X-rays & Diagnostic Imaging No charge after ded. No charge after ded.
Urgent Care No charge after ded. No charge after ded.
Emergency Room* No charge after ded. No charge after ded.
Emergency Transportation* No charge after ded. No charge after ded.
Inpatient Facility Fee No charge after ded. No charge after ded.
Inpatient Hospital Physician & Surgical Services No charge after ded. No charge after ded.
Outpatient Facility Fee No charge after ded. No charge after ded.
Outpatient Surgery Physician/Surgical Services No charge after ded. No charge after ded.
Labs & Diagnostics No charge after ded. No charge after ded.
Mental/Behavioral Health & Substance Use Disorder Outpatient Services No charge after ded. No charge after ded.
Rehabilitation Outpatient Services (Includes Speech, Occupational, Physical Therapy) No charge after ded. No charge after ded.
Skilled Nursing Facility No charge after ded. No charge after ded.
Pediatric Vision- Routine Eye Exam (1 visit per year) 100% Covered 100% Covered
Pediatric Vision- Eyeglasses (frames, 1 per year) 100% Covered 100% Covered
Pedicatric Vision- Lenses (per pair) 100% Covered 100% Covered
Pharmacy* (Generic / Preferred / Non-preferred / Specialty) $20 / No charge after ded. / No charge after ded. / No charge after ded. No charge after ded. / No charge after ded. / No charge after ded. / No charge after ded.
Plan Name Balanced Care 1 (2016) – Standard Balanced Care 2 (2016) – Standard Balanced Care 10 (2016) – Standard
Medical Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim.(Ind/Fam) $5,500/$11,000 $6,500/$13,000 $4,500/$9,000
Prescription Drug Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. (Ind/Fam) Integrated with medical ded. Integrated with medical ded. Integrated with medical ded.
Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services (Ind/Fam) $6,500/$13,000 $6,500/$13,000 $6,500/$13,000
Annual Well Visit/ Preventive Care No charge No charge No charge
PCP Office Visit 30 30 20
Specialist Office Visit 60 60 40
Imaging (CT/PET Scans, MRIs) 20% after ded. No charge after ded. 20% after ded.
X-rays & Diagnostic Imaging 20% after ded. No charge after ded. 20% after ded.
Urgent Care 100 100 100
Emergency Room* 20% after ded. No charge after ded. 20% after ded.
Emergency Transportation* 20% after ded. No charge after ded. 20% after ded.
Inpatient Facility Fee 20% after ded. No charge after ded. 20% after ded.
Inpatient Hospital Physician & Surgical Services 20% after ded. No charge after ded. 20% after ded.
Outpatient Facility Fee 20% after ded. No charge after ded. 20% after ded.
Outpatient Surgery Physician/Surgical Services 20% after ded. No charge after ded. 20% after ded.
Labs & Diagnostics 20% after ded. No charge after ded. 20% after ded.
Mental/Behavioral Health & Substance Use Disorder Outpatient Services 30 30 20
Rehabilitation Outpatient Services (Includes Speech, Occupational, Physical Therapy) 20% after ded. No charge after ded. 20% after ded.
Skilled Nursing Facility 20% after ded. No charge after ded. 20% after ded.
Pediatric Vision- Routine Eye Exam (1 visit per year) 100% Covered 100% Covered 100% Covered
Pediatric Vision- Eyeglasses (frames, 1 per year) 100% Covered 100% Covered 100% Covered
Pedicatric Vision- Lenses (per pair) 100% Covered 100% Covered 100% Covered
Pharmacy* (Generic / Preferred / Non-preferred / Specialty) $10 / $50 / 20% after Rx ded. / 20% after Rx ded. $15 / $50 / No charge after ded. / No charge after ded. $10 / $50 / 20% after ded. / 20% after ded.
Plan Name Secure Care 1 (2016) with 3 Free PCP Visits – Standard
Medical Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. (Ind/Fam) $1,000/$2,000
Prescription Drug Deductiblea specified amount of money that the insured must pay before an insurance company will pay a claim. (Ind/Fam) $500/$1,000
Out-of-Pocket MaximumAn out-of-pocket maximum is the most you'll have to pay during a policy period (usually a year) for health care services (Ind/Fam) $6,350/$12,700
Annual Well Visit/ Preventive Care No charge
PCP Office Visit 20% after ded.
Specialist Office Visit 20% after ded.
Imaging (CT/PET Scans, MRIs) 20% after ded.
X-rays & Diagnostic Imaging 20% after ded.
Urgent Care 20% after ded.
Emergency Room* $250 after ded.
Emergency Transportation* 20% after ded.
Inpatient Facility Fee 20% after ded.
Inpatient Hospital Physician & Surgical Services 20% after ded.
Outpatient Facility Fee 20% after ded.
Outpatient Surgery Physician/Surgical Services 20% after ded.
Labs & Diagnostics 20% after ded.
Mental/Behavioral Health & Substance Use Disorder Outpatient Services 20% after ded.
Rehabilitation Outpatient Services (Includes Speech, Occupational, Physical Therapy) 20% after ded.
Skilled Nursing Facility 20% after ded.
Pediatric Vision- Routine Eye Exam (1 visit per year) 100% Covered
Pediatric Vision- Eyeglasses (frames, 1 per year) 100% covered
Pedicatric Vision- Lenses (per pair) 100% covered
Pharmacy* (Generic / Preferred / Non-preferred / Specialty) $10 / $25 after Rx ded. / $75 after Rx ded. / 30% after Rx ded.

Ambetter Texas Plans

Drug Formulary

Provider List

Ambetter Texas Coverage Map
Plan Brochures
Plan Name Deductible Out-Of-Pocket Coinsurance Brochures Summary of Benefits
Ambetter Secure Care 1 (2016) with 3 Free PCP Visits (Zero Cost Share) $0 $0 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 1 (2016) (Zero Cost Share) $0 $0 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 2 (2016) (Zero Cost Share) $0 $0 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 10 (2016) (Zero Cost Share) $0 $0 0% Coinsurance View PDF View PDF
Ambetter Essential Care 1 (2016) (Zero Cost Share) $0 $0 0% Coinsurance View PDF View PDF
Ambetter Essential Care 5 (2016) with 3 Free PCP Visits (Zero Cost Share) $0 $0 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 1 (2016) + Vision (Zero Cost Share) $0 $0 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 2 (2016) + Vision (Zero Cost Share) $0 $0 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 10 (2016) + Vision (Zero Cost Share) $0 $0 0% Coinsurance View PDF View PDF
Ambetter Essential Care 1 (2016) + Vision (Zero Cost Share) $0 $0 0% Coinsurance View PDF View PDF
Ambetter Essential Care 5 (2016) with 3 Free PCP Visits + Vision (Zero Cost Share) $0 $0 0% Coinsurance View PDF View PDF
Ambetter Secure Care 1 (2016) with 3 Free PCP Visits (Limited Cost Share) $1,000 $6,350 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 1 (2016) (Limited Cost Share) $5,500 $6,500 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 2 (2016) (Limited Cost Share) $6,500 $6,500 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 10 (2016) (Limited Cost Share) $4,500 $6,500 20% Coinsurance View PDF View PDF
Ambetter Essential Care 1 (2016) (Limited Cost Share) $6,800 $6,800 0% Coinsurance View PDF View PDF
Ambetter Essential Care 5 (2016) with 3 Free PCP Visits (Limited Cost Share) $6,800 $6,800 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 1 (2016) + Vision (Limited Cost Share) $5,500 $6,500 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 2 (2016) + Vision (Limited Cost Share) $6,500 $6,500 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 10 (2016) + Vision (Limited Cost Share) $4,500 $6,500 20% Coinsurance View PDF View PDF
Ambetter Essential Care 1 (2016) + Vision (Limited Cost Share) $6,800 $6,800 0% Coinsurance View PDF View PDF
Ambetter Essential Care 5 (2016) with 3 Free PCP Visits + Vision (Limited Cost Share) $6,800 $6,800 0% Coinsurance View PDF View PDF
Ambetter Secure Care 1 (2016) with 3 Free PCP Visits (Standard Cost Share) $1,000 $6,350 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 1 (2016) (Standard Cost Share) $5,500 $6,500 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 2 (2016) (Standard Cost Share) $6,500 $6,500 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 10 (2016) (Standard Cost Share) $4,500 $6,500 20% Coinsurance View PDF View PDF
Ambetter Essential Care 1 (2016) (Standard Cost Share) $6,800 $6,800 0% Coinsurance View PDF View PDF
Ambetter Essential Care 5 (2016) with 3 Free PCP Visits (Standard Cost Share) $6,800 $6,800 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 1 (2016) + Vision (Standard Cost Share) $5,500 $6,500 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 2 (2016) + Vision (Standard Cost Share) $6,500 $6,500 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 10 (2016) + Vision (Standard Cost Share) $4,500 $6,500 20% Coinsurance View PDF View PDF
Ambetter Essential Care 1 (2016) + Vision (Standard Cost Share) $6,800 $6,800 0% Coinsurance View PDF View PDF
Ambetter Essential Care 5 (2016) with 3 Free PCP Visits + Vision (Standard Cost Share) $6,800 $6,800 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 1 (2016) (73% AV Cost Share) $3,500 $5,000 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 2 (2016) (73% AV Cost Share) $4,500 $4,500 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 10 (2016) (73% AV Cost Share) $4,000 $5,000 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 1 (2016) + Vision (73% AV Cost Share) $3,500 $5,000 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 2 (2016) + Vision (73% AV Cost Share) $4,500 $4,500 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 10 (2016) + Vision (73% AV Cost Share) $4,000 $5,000 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 1 (2016) (87% AV Cost Share) $350 $2,250 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 2 (2016) (87% AV Cost Share) $1,750 $1,750 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 10 (2016) (87% AV Cost Share) $1,000 $1,750 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 1 (2016) + Vision (87% AV Cost Share) $350 $2,250 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 2 (2016) + Vision (87% AV Cost Share) $1,750 $1,750 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 10 (2016) + Vision (87% AV Cost Share) $1,000 $1,750 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 1 (2016) (94% AV Cost Share) $0 $650 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 2 (2016) (94% AV Cost Share) $550 $550 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 10 (2016) (94% AV Cost Share) $250 $550 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 1 (2016) + Vision (94% AV Cost Share) $0 $650 20% Coinsurance View PDF View PDF
Ambetter Balanced Care 2 (2016) + Vision (94% AV Cost Share) $550 $550 0% Coinsurance View PDF View PDF
Ambetter Balanced Care 10 (2016) + Vision (94% AV Cost Share) $250 $550 20% Coinsurance View PDF View PDF
Pharmacy Resources
Ambetter from Superior HealthPlan is committed to providing appropriate, high quality, and cost effective drug therapy to all Ambetter from Superior HealthPlan members. Ambetter works with providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered. Ambetter covers prescription medications and certain over-the-counter (OTC) medications when ordered by a practitioner. The pharmacy program does not cover all medications. Some medications require prior authorization (PA) or have limitations on age, dosage, and maximum quantities. Choosing a pharmacy Ambetter has a variety of convenient in-network pharmacies. These include: HEB, CVS and Walmart, as well as many independent pharmacies in your area. To find a network pharmacy near you, use the Find a Provider Tool and follow these steps:

  • Enter your zip code or address, or click Use my Current location.
  • Click Detailed Search and select Pharmacy from the Type of Provider drop-down menu.
  • If you are looking for a specific pharmacy like Home Infusion Therapy or Long Term Care, select that under the Specialty drop-down menu. Otherwise, you can skip this step.
  • If you need help finding a pharmacy, please call Member Services at 1-877-687-1196. Relay Texas/TTY users should call 1-800-735-2989.

More on Ambetter’s pharmacy program. To find the cost of your medications please use the Drug Cost Tool. Use the Preferred Drug List to find more information on the drugs that Ambetter covers.

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