Ambetter from Superior HealthPlan provides quality healthcare solutions that help residents of Wisconsin live better. With a variety of affordable coverage options, they make it easier to stay healthy.
| 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. |
When you begin shopping for a Marketplace health plan, you’ll see plan options with different metal tiers such as Gold, Silver and Bronze plans. But the only difference between these plans is how much premium you’ll pay each month and how much you’ll pay for certain medical services. A Bronze plan typically gives you lower monthly premium payments, but potentially higher out-of-pocket costs – if you end up needing a lot of care. And a Gold plan may have higher monthly premiums, but that helps you limit your out-of-pocket costs later. If you’re looking for a balance on your monthly premium payments and your out-of-pocket costs, Silver plans provide just that. And, Silver plans are the only plans with additional out-of-pocket payment reductions (cost sharing reductions)! This helps lower the costs of your copays, deductibles and coinsurance. So, if you are eligible for a subsidy and cost sharing, Silver plans offer the highest value.
Ambetter Wisconsin 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]
Email: [email protected]