AmBetter Minnesota
Plan Overviews
Ambetter from Superior HealthPlan provides quality healthcare solutions that help residents of Minnesota live better. With a variety of affordable coverage options, they make it easier to stay healthy.
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| Plan Name | Essential Care 1 (2016) – Standard | Essential Care 5 (2016) with 3 Free PCP Visits – Standard |
| Medical Deductible (Ind/Fam) | $6,800/$13,600 | $6,800/$13,600 |
| Prescription Drug Deductible (Ind/Fam) | Integrated with medical ded. | Integrated with medical ded. |
| Out-of-pocket Maximum (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 Deductible (Ind/Fam) | $5,500/$11,000 | $6,500/$13,000 | $4,500/$9,000 |
| Prescription Drug Deductible (Ind/Fam) | Integrated with medical ded. | Integrated with medical ded. | Integrated with medical ded. |
| Out-of-pocket Maximum (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 Deductible (Ind/Fam) | $1,000/$2,000 |
| Prescription Drug Deductible (Ind/Fam) | $500/$1,000 |
| Out-of-pocket Maximum (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. |
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Ambetter Minnesota 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 |
Contact Us
Phone: (312) 726-6565
Email: [email protected]