Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered Services

Coverage Period: 01/01/2022 – 12/31/2022

Ambetter from Peach State Health Plan: Coverage for: Individual/Family | Plan Type: HMO
Ambetter Balanced Care 28
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would
share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit
https://ambetter.pshpgeorgia.com/2022-brochures.html, or call 1-877-687-1180 (TTY/TDD 1-877-941-9231). For general definitions of common terms, such as
allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms, see the Glossary. You can view the Glossary at
https://www.healthcare.gov/sbc-glossary or call 1-877-687-1180 (TTY/TDD 1-877-941-9231) to request a copy.
Important Questions Answers Why This Matters:
What is the overall
$0 individual / $0 family. See the Common Medical Events chart below for your cost for services this plan covers.
deductible?
Yes, except for Preferred Brand This plan covers some items and services even if you haven’t yet met the deductible amount. But
Are there services
(Tier 2), Non-Preferred Brand a copayment or coinsurance may apply. For example, this plan covers certain preventive services
covered before you meet
(Tier 3), and Specialty drugs (Tier without cost-sharing and before you meet your deductible. See a list of covered preventive
your deductible?
4). services at https://www.healthcare.gov/coverage/preventive-care-benefits/.
Yes, $1,500 individual / $3,000
Are there other
family for prescription drug You must pay all of the costs for these services up to the specific deductible amount before this
deductibles for specific
coverage. There are no other plan begins to pay for these services.
services?
specific deductibles.
For network providers: $8,200
The out-of-pocket limit is the most you could pay in a year for covered services. If you have other
What is the out-of-pocket individual / $16,400 family. Not
family members in this plan, they have to meet their own out-of-pocket limits until the overall
limit for this plan? applicable for out-of-network
family out-of-pocket limit has been met.
providers.
Premiums, balance-billing charges
What is not included in
and health care this plan doesn’t Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
the out-of-pocket limit?
cover.
Yes. See This plan uses a provider network. You will pay less if you use a provider in the plan’s network.
https://ambetter.pshpgeorgia.com/ You will pay the most if you use an out-of-network provider, and you might receive a bill from a
Will you pay less if you
findadoc or call 1-877-687-1180 provider for the difference between the provider’s charge and what your plan pays (balance
use a network provider?
(TTY/TDD 1-877-941-9231) for a billing). Be aware, your network provider might use an out-of-network provider for some services
list of network providers. (such as lab work). Check with your provider before you get services.
Do you need a referral to
No. You can see the specialist you choose without a referral.
see a specialist?

SBC-70893GA0010034-01 Underwritten by Ambetter of Peach State Inc. Page 1 of 7

 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.

Common What You Will Pay Limitations, Exceptions, & Other

Services You May Need Network Provider Out-of-Network Provider
Medical Event Important Information
(You will pay the least) (You will pay the most)
Unlimited Virtual Care Visits received from
Primary care visit to treat an
$50 Copay / visit Not covered Ambetter Telehealth covered at No Charge,
injury or illness
providers covered in full.
If you visit a health
Specialist visit $90 Copay / visit Not covered Covered No Limit.
care provider’s office
or clinic You may have to pay for services that aren’t
Preventive care/screening/ preventive. Ask your provider if the services
No charge Not covered
immunization needed are preventive. Then check what
your plan will pay for.
$50 Copay / test for
laboratory & professional Prior authorization may be required. Covered
services No Limit. Other places of service may include
Hospital, Emergency Room, or Outpatient
50% Coinsurance for x-
Facility.
Diagnostic test (x-ray, blood ray & diagnostic imaging
Not covered
work) 50% Coinsurance for
If you have a test Failure to obtain prior authorization for any
laboratory & professional service that requires prior authorization will
services and x-ray & result in a denial of benefits. See your policy
diagnostic imaging at for more details.
other places of service
Prior authorization may be required. Covered
Imaging (CT/PET scans, MRIs) 50% Coinsurance Not covered
No Limit.
Preferred Generic Retail: Prior authorization may be required.
If you need drugs to $5 Copay / prescription Prescription drugs are provided up to 30 days
treat your illness or Generic drugs (Tier 1) Not covered retail and up to 90 days through mail order.
condition Generic Retail: $30 Mail orders are subject to 2.5x retail cost-
More information about Copay / prescription sharing amount.
prescription drug Retail: 50% Coinsurance;
Prior authorization may be required.
coverage is available at Preferred brand drugs (Tier 2) subject to Rx drug Not covered
Prescription drugs are provided up to 30 days
https://ambetter.pshpg deductible
retail and up to 90 days through mail order.
eorgia.com/2022formu Retail: 50% Coinsurance;
Non-preferred brand drugs Mail orders are subject to 2.5x retail cost-
lary. subject to Rx drug Not covered
(Tier 3) sharing amount. $1,500 individual / $3,000
deductible

*For more information about limitations and exceptions, see plan or policy document at https://api.centene.com/eoc/2022/70893GA001.pdf. Page 2 of 7
 Common What You Will Pay Limitations, Exceptions, & Other
Services You May Need Network Provider Out-of-Network Provider
Medical Event Important Information
(You will pay the least) (You will pay the most)
family Rx drug deductible for preferred brand,
non-preferred brand, and specialty drugs.
Prior authorization may be required.
Prescription drugs are provided up to 30 days
Retail: 50% Coinsurance;
retail and up to 30 days through mail order.
Specialty drugs (Tier 4) subject to Rx drug Not covered
$1,500 individual / $3,000 family Rx drug
deductible
deductible for preferred brand, non-preferred
brand, and specialty drugs.
Facility fee (e.g., ambulatory Prior authorization may be required. Covered
50% Coinsurance Not covered
If you have outpatient surgery center) No Limit.
surgery Prior authorization may be required. Covered
Physician/surgeon fees 50% Coinsurance Not covered
No Limit.
50% Coinsurance;
Emergency room care 50% Coinsurance Covered No Limit.
deductible does not apply
Covered No Limit. Note: Prior authorization is
If you need immediate
Emergency medical 50% Coinsurance; not required for emergency transport,
medical attention 50% Coinsurance
transportation deductible does not apply however, all non-emergent transport requires
prior authorization.
Urgent care $60 Copay / visit Not covered Covered No Limit.
Prior authorization may be required. Covered
Facility fee (e.g., hospital room) 50% Coinsurance Not covered
If you have a hospital No Limit.
stay Prior authorization may be required. Covered
Physician/surgeon fees 50% Coinsurance Not covered
No Limit.
$50 Copay/Office Visit; Prior authorization may be required. Covered
If you need mental Outpatient services 50% Coinsurance for Not covered No Limit. (PCP and other practitioner visits do
health, behavioral other outpatient services not require prior authorization).
health, or substance
Prior authorization may be required. Covered
abuse services Inpatient services 50% Coinsurance Not covered
No Limit.
Prior authorization not required for deliveries
within the standard timeframe per federal
If you are pregnant Office visits $50 Copay / visit Not covered regulation, but may be required for other
services. Cost-sharing does not apply for
preventive services, such as routine pre-natal

*For more information about limitations and exceptions, see plan or policy document at https://api.centene.com/eoc/2022/70893GA001.pdf. Page 3 of 7
 Common What You Will Pay Limitations, Exceptions, & Other
Services You May Need Network Provider Out-of-Network Provider
Medical Event Important Information
(You will pay the least) (You will pay the most)
and post-natal screenings. Depending on the
type of services, coinsurance, deductible or
copayment may apply. Maternity care may
include tests and services described
elsewhere in the SBC (i.e. ultrasound).
Childbirth/delivery professional Prior authorization may be required. Cost-
50% Coinsurance Not covered sharing does not apply for preventive
services
services. Depending on the type of services,
copayment, coinsurance or deductible may
Childbirth/delivery facility apply. Maternity care may include tests and
50% Coinsurance Not covered
services services described elsewhere in the SBC (i.e.
ultrasound).
Prior authorization may be required. Limited
Home health care 50% Coinsurance Not covered
to 120 visits per year.
Prior authorization may be required. Limited
to a combined maximum of 40 visits per year
for chiropractic care, speech therapy,
Rehabilitation services 50% Coinsurance Not covered physical therapy and occupational therapy.
Note: Limits do not apply when provided for a
mental health/substance use disorder
diagnosis.
If you need help Prior authorization may be required. Limited
recovering or have to a combined maximum of 40 visits per year
other special health for chiropractic, speech therapy, physical
needs Habilitation services 50% Coinsurance Not covered therapy and occupational therapy. Note:
Habilitation therapy limits do not apply when
provided for a mental health/substance use
disorder diagnosis.
Prior authorization may be required. Limited
Skilled nursing care 50% Coinsurance Not covered
to 60 days per year.
Prior authorization may be required. Covered
Durable medical equipment 50% Coinsurance Not covered
no limit.
Prior authorization may be required. Covered
Hospice services 50% Coinsurance Not covered
No Limit.

*For more information about limitations and exceptions, see plan or policy document at https://api.centene.com/eoc/2022/70893GA001.pdf. Page 4 of 7
 Common What You Will Pay Limitations, Exceptions, & Other
Services You May Need Network Provider Out-of-Network Provider
Medical Event Important Information
(You will pay the least) (You will pay the most)
Children’s eye exam No charge Not covered Limited to 1 visit per year.
If your child needs
Children’s glasses No charge Not covered Limited to 1 item per year.
dental or eye care
Children’s dental check-up Not covered Not covered -----None-----

Excluded Services & Other Covered Services:

Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
• Abortion (Except in cases of rape, incest, or • Dental care • Non-emergency care when traveling outside the
when the life of the mother is endangered) U.S.
• Hearing aids
• Acupuncture • Private-duty nursing
• Long-Term Care (Long Term Acute Care is a
• Bariatric surgery covered benefit. Long Term Nursing Care/ • Routine eye care (Adult)
Custodial Care is not a covered benefit.)
• Cosmetic surgery

Other Covered Services (Limitations may apply to these services. This isn’t a complete list. Please see your plan document.)
• Chiropractic care (Limited to a combined • Infertility treatment (Limited to coverage for the • Weight loss programs (4 Visits per year for
maximum of 40 visits per year for chiropractic diagnosis of infertility only) nutritional counseling)
care, speech therapy, physical therapy and
• Routine foot care (Coverage is limited to diabetes
occupational therapy.)
care only.)

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those
agencies is: Ambetter from Peach State Health Plan at 1-877-687-1180 (TTY/TDD 1-877-941-9231); Georgia Office of Insurance and Safety Fire Commissioner, Two
Martin Luther King, Jr. Drive, West Tower, Suite 716, Atlanta, Georgia 30334, Phone No. 1-404-656-2070 or 1-800-656-2298. Other coverage options may be
available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit
www.HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a
grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide
complete information on how to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance,
contact: Georgia Office of Insurance and Safety Fire Commissioner, Two Martin Luther King, Jr. Drive, West Tower, Suite 716, Atlanta, Georgia 30334, Phone No. 1-
404-656-2070 or 1-800-656-2298.

Does this plan provide Minimum Essential Coverage? Yes.

*For more information about limitations and exceptions, see plan or policy document at https://api.centene.com/eoc/2022/70893GA001.pdf. Page 5 of 7
Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,
CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

Does this plan meet Minimum Value Standards? Not Applicable.

If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

Language Access Services:

Spanish (Español): Para obtener asistencia en Español, llame al 1-877-687-1180 (TTY/TDD 1-877-941-9231).
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-877-687-1180 (TTY/TDD 1-877-941-9231).
Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-877-687-1180 (TTY/TDD 1-877-941-9231).
Navajo (Dine): Dinek'ehgo shika at'ohwol ninisingo, kwiijigo holne' 1-877-687-1180 (TTY/TDD 1-877-941-9231).

To see examples of how this plan might cover costs for a sample medical situation, see the next section.

Page 6 of 7
About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be
different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost-sharing
amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of
costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby Managing Joe’s Type 2 Diabetes Mia’s Simple Fracture
(9 months of in-network pre-natal care and a (a year of routine in-network care of a well- (in-network emergency room visit and follow up
hospital delivery) controlled condition) care)
◼ The plan’s overall deductible $0 ◼ The plan’s overall deductible $0 ◼ The plan’s overall deductible $0
◼ Specialist copayment $90 ◼ Specialist copayment $90 ◼ Specialist copayment $90
◼ Hospital (facility) coinsurance 50% ◼ Hospital (facility) coinsurance 50% ◼ Hospital (facility) coinsurance 50%
◼ Other coinsurance 50% ◼ Other coinsurance 50% ◼ Other coinsurance 50%
This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical supplies)
Childbirth/Delivery Professional Services disease education) Diagnostic tests (x-ray)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Durable medical equipment (crutches)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Rehabilitation services (physical therapy)
Specialist visit (anesthesia) Durable medical equipment (glucose meter)
Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800

In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles* $10 Deductibles* $1,500 Deductibles* $10
Copayments $600 Copayments $700 Copayments $300
Coinsurance $4,400 Coinsurance $1,400 Coinsurance $1,200
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $60 Limits or exclusions $20 Limits or exclusions $0
The total Peg would pay is $5,070 The total Joe would pay is $3,620 The total Mia would pay is $1,510

*Note: This plan has other deductibles for specific services included in this coverage example. See “Are there other deductibles for specific services?” row above.

The plan would be responsible for the other costs of these EXAMPLE covered services. Page 7 of 7
 Si usted, o alguien a quien está ayudando, tiene preguntas acerca de Ambetter de Peach State Health Plan, tiene derecho a obtener
Spanish: ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-877-687-1180
(TTY/TDD 1-877-941-9231).

Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Ambetter from Peach State Health Plan, quý vị sẽ có quyền được giúp và
Vietnamese: có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1-877-687-1180
(TTY/TDD 1-877-941-9231).

만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 Ambetter from Peach State Health Plan 에 관해서 질문이 있다면 귀하는 그러한 도움과
Korean: 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는 1-877-687-1180
(TTY/TDD 1-877-941-9231)로 전화하십시오.
如果您，或是您正在協助的對象，有關於 Ambetter from Peach State Health Plan 方面的問題，您有權利免費以您的母語得到幫助和訊
Chinese:
息。如果要與一位翻譯員講話，請撥電話 1-877-687-1180 (TTY/TDD 1-877-941-9231)。

જે તમને અથવા તમે જેમની મદદ કરી રહ્યા હોય તેમને, Ambetter from Peach State Health Plan વવશે કોઈ પ્રશ્ન હોય તો તમને, કોઈ ખર્ચ વવના
Gujarati: તમારી ભાષામાાં મદદ અને માહહતી પ્રાપ્ત કરવાનો અવિકાર છે . દુ ભાવષયા સાથે વાત કરવા માટે 1-877-687-1180 (TTY/TDD 1-877-941-9231)
ઉપર કૉલ કરો.

Si vous-même ou une personne que vous aidez avez des questions à propos d’Ambetter from Peach State Health Plan, vous avez le
French: droit de bénéficier gratuitement d’aide et d’informations dans votre langue. Pour parler à un interprète, appelez le
1-877-687-1180 (TTY/TDD 1-877-941-9231).

እርስዎ ወይም እርሰዎ የሚርዱት ሰው ስለ Ambetter from Peach State Health Plan ግብር ጥያቄ ካለዎት ያለምንም ወጪ በቋንቋዎ ድጋፍ እንዲሁም መረጃ የማግኘት መብት
Amharic:
አለዎት፣ ፣ አስተርጓሚ ለማነጋገር በ 1-877-687-1180 (TTY/TDD 1-877-941-9231) ይደውሉ፤ ፤

आप या जिसकी आप मदद कर रहे हैं उनके, Ambetter from Peach State Health Plan के बारे में कोई सवाल हों, तो आपको बबना ककसी खर्च
Hindi: के अपनी भाषा में मदद और िानकारी प्राप्त करने का अधिकार है। ककसी दभ
ु ाषषये से बात करने के ललए 1-877-687-1180
(TTY/TDD 1-877-941-9231) पर कॉल करें ।

French Si oumenm, oubyen yon moun w ap ede, gen kesyon nou ta renmen poze sou Ambetter from Peach State Health Plan, ou gen tout
dwa pou w jwenn èd ak enfòmasyon nan lang manman w san sa pa koute w anyen. Pou w pale avèk yon entèprèt, sonnen nimewo
Creole:
1-877-687-1180 (TTY/TDD 1-877-941-9231).
В случае возникновения у вас или у лица, которому вы помогаете, каких-либо вопросов о программе страхования Ambetter
Russian: from Peach State Health Plan вы имеете право получить бесплатную помощь и информацию на своем родном языке. Чтобы
поговорить с переводчиком, позвоните по телефону 1-877-687-1180 (TTY/TDD 1-877-941-9231).

‫ لديك الحق في الحصول على المساعدة والمعلومات الضرورية بلغتك‬، Ambetter from Peach State Health Plan ‫إذا كان لديك أو لدى شخص تساعده أسئلة حول‬
Arabic:
.(TTY/TDD 1-877-941-9231) 1-877-687-1180 ‫ للتحدث مع مترجم اتصل بـ‬.‫من دون أية تكلفة‬

Portuguese: Se você, ou alguém a quem você está ajudando, tem perguntas sobre o Ambetter from Peach State Health Plan, você tem o direito de
obter ajuda e informação em seu idioma e sem custos. Para falar com um intérprete, ligue para 1-877-687-1180
(TTY/TDD 1-877-941-9231).

‫ از اين حق برخورداريد که کمک و اطالعات را‬،‫ داريد‬Ambetter from Peach State Health Plan ‫ يا کسي که به او کمک مي کنيد سؤالي در مورد‬،‫اگر شما‬
Persian:
‫( تماس بگيريد۔‬TTY/TDD 1-877-941-9231) 1-877-687-1180 ‫بصورت رايگان به زبان خود دريافت کنيد۔ براي صحبت کردن با مترجم با شماره‬

Falls Sie oder jemand, dem Sie helfen, Fragen zu Ambetter from Peach State Health Plan hat, haben Sie das Recht, kostenlose Hilfe
German: und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer
1-877-687-1180 (TTY/TDD 1-877-941-9231) an.

Ambetter from Peach State Health Plan について何かご質問がございましたらご連絡ください。 ご希望の言語によるサポートや情報を無料でご提供いた

Japanese:
します。 通訳が必要な場合は、1-877-687-1180 (TTY/TDD 1-877-941-9231)までお電話ください。

AMB16-GA-C-00076
 Statement of Non-Discrimination

Ambetter from Peach State Health Plan complies with applicable Federal civil rights laws and does not
discriminate on the basis of race, color, national origin, age, disability, or sex. Ambetter from Peach State
Health Plan does not exclude people or treat them differently because of race, color, national origin, age,
disability, or sex.

Ambetter from Peach State Health Plan:

• Provides free aids and services to people with disabilities to communicate effectively with us,
such as:
 Qualified sign language interpreters
 Written information in other formats (large print, audio, accessible electronic formats,
other formats)
• Provides free language services to people whose primary language is not English, such as:
 Qualified interpreters
 Information written in other languages

If you need these services, contact Ambetter from Peach State Health Plan at 1-877-687-1180 (TTY/TDD
1-877-941-9231).

If you believe that Ambetter from Peach State Health Plan has failed to provide these services or
discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file
a grievance with: Ambetter from Peach State Health Plan Complaints Department, 1100 Circle 75
Parkway, Suite 1100, Atlanta, GA 30339, 1-877-687-1180 (TTY/TDD 1-877-941-9231), Fax 1-866-532-
8855. You can file a grievance by mail, fax, or email. If you need help filing a grievance, Ambetter from
Peach State Health Plan is available to help you. You can also file a civil rights complaint with the U.S.

Department of Health and Human Services, Office for Civil Rights electronically through the Office for
Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone
at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH
Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

AMB21-GA-C-00598