Ambetter Essential Care 1 (2018) (Bronze Level) - Texas .

29418TX0140006-01AmbetterYOUR HEALTH. OUR PRIORITY.Ambetter from Superior HealthPlan providesquality healthcare solutions that can help youlive better. With coverage options from Ambetter,it’s easier to take charge of your health.Your health is important to us. And you deserve to getthe most out of your health insurance plan.By choosing Ambetter from Superior HealthPlan, you’llreceive affordable, quality healthcare coverage thatincludes preventive care and whole health services.And our plans also give you access to valuable programs,educational tools and support. So you can focus onstaying healthy.Our commitment to you goes beyond the doctor’s office.Ambetter from Superior HealthPlan is active in your localcommunity—because we’re dedicated to helping you leada fulfilling life.To learn more, visit Ambetter.SuperiorHealthPlan.com.Comprehensive Medical CareComplete medical coverage that includesall of your Essential Health Benefits.Rewards ProgramEarn up to 250 per year when you take stepsto be healthy.Prescription CoverageGet coverage for your medical prescriptions.24/7 Nurse Advice LineCall and talk to a registered nurse 24 hoursa day, 7 days a week to ask questions or getmedical advice.Vision CoveragePediatric coverage for services such as eyeexams and prescription eyewear. Optional adultvision coverage only offered on some BalancedCare and Essential Care plans.Ambetter from Superior HealthPlan is a Qualified Health Plan issuer in the Texas Health Insurance Marketplace and does notdiscriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in theadministration of the plan, including enrollment and benefit determinations.AMB17-TX-C-00020This is a solicitation for insurance. 2017 Celtic Insurance Company. All rights reserved.

AmbetterRewards ProgramYou Can EarnUp to 250Per Year!Ourrewards program helpsyou earn rewards for taking care of yourself.Use your rewards to help pay for:Just complete healthy activities,such as your annual wellness examwith your primary care provider (PCP)rewards.and earn Monthly premium payments Doctor copays* Deductibles Coinsurance* My Health Pays rewards cannot be used for pharmacy copays.Earn your rewards automaticallyon your My Health Pays Visa Prepaid Card!You will receive your My HealthPays card in the mail when youearn your first reward.This card is issued by The Bancorp Bank pursuant to a license from Visa U.S.A Inc. The Bancorp Bank; Member FDIC.Card cannot be used everywhere Visa debit cards are accepted. See Cardholder Agreement for complete usage restrictions.To learn more aboutrewards, visitAmbetter.SuperiorHealthPlan.com.

Ambetter Essential Care 1 (2018)(Bronze Level)Medical Annual DeductibleIndividual: 6,800; Family: 13,600Medical Coinsurance0% CoinsurancePrescription Drug Annual DeductibleIndividual: Integrated with medical deductible;Family: Integrated with medical deductiblePrescription Drug CoinsuranceIntegrated with medical coinsuranceMaximum Annual Out-of-pocketIndividual: 6,800; Family: 13,600Covered benefits are for In-network providers only. Tofind our most up to date list of in-network providers, pleasevisit our website at Ambetter.SuperiorHealthPlan.com andselect “Find a Provider” in the main menu. Providers listedin the Ambetter from Superior HealthPlan online directoryare in-network.Emergency ServicesYour Cost (In-Network Providers only)Out-of-NetworkSubject to DeductibleEmergency Room ServicesNo charge after deductibleNo charge after deductibleYesEmergency Transportation/Ambulance (Air or Ground)No charge after deductibleNo charge after deductibleYesUrgent CareNo charge after deductibleNot coveredYesProvider ServicesAnnual Well Visit/Screening/Immunization/Well BabyNo chargeNot coveredNoPrimary Care Visit to treat an injury or illness and MaternityNo charge after deductibleNot coveredYesSpecialist Visit (e.g. Cardiology, Podiatry, Chiropractic Care)No charge after deductibleNot coveredYesImaging (CT/PET Scans, MRIs)No charge after deductibleNot coveredYesX-rays & Diagnostic ImagingNo charge after deductibleNot coveredYesNo charge after deductibleNot coveredYesInpatient & Outpatient ServicesInpatient Facility Fee (Includes Mental Health, SubstanceUse and Maternity)Inpatient Hospital Physician & Surgical ServicesNo charge after deductibleNot coveredYesOutpatient Facility Fee (e.g. Ambulatory Surgery Center)No charge after deductibleNot coveredYesOutpatient Surgery Physician/Surgical ServicesNo charge after deductibleNot coveredYesLaboratory Outpatient & Professional ServicesNo charge after deductibleNot coveredYesMental/Behavioral Health & Substance Use DisorderOutpatient ServicesNo charge after deductibleNot coveredYesRehabilitation Outpatient Services (includes Speech,Occupational and Physical Therapy)No charge after deductibleNot coveredYes100% CoveredNot coveredNoOther Medical ServicesPediatric VisionRoutine Eye Exam (1 visit per year)Eyeglasses (frames, 1 item per year)100% CoveredNot coveredNoLenses (per pair)100% CoveredNot coveredNoPrescription DrugsGenerics* 20 CopayNot coveredNoPreferred Brand DrugsNo charge after deductibleNot coveredYesNon-preferred Brand DrugsNo charge after deductibleNot coveredYesSpecialty DrugsNo charge after deductibleNot coveredYes*If the cost of the generic drug is less than the copay, you pay the lesser amount.Information shown represents a Standard Cost Share Plan. Our plans do not cover all health care expenses. Covered benefits will vary by state and are for in-network providers only. For comprehensivebenefit detail, members should review their Evidence of Coverage and Schedule of Benefits prior to receiving services. Exclusions and limitations may apply.For help understanding the terms used above, see the Words to Know page on ealthPlan.com 1-877-687-1196 (Relay Texas/TTY: 1-800-735-2989)This is a solicitation for insurance. 2017 Celtic Insurance Company. All rights reserved.

Statement of Non-DiscriminationAmbetter from Superior HealthPlan complies with applicable Federal civil rights laws and does notdiscriminate on the basis of race, color, national origin, age, disability, or sex. Ambetter from SuperiorHealthPlan does not exclude people or treat them differently because of race, color, national origin, age,disability, or sex.Ambetter from Superior HealthPlan: Provides free aids and services to people with disabilities to communicate effectively with us,such as: Qualified sign language interpretersWritten information in other formats (large print, audio, accessible electronic formats, otherformats)Provides free language services to people whose primary language is not English, such as: Qualified interpretersInformation written in other languagesIf you need these services, contact Ambetter from Superior HealthPlan at 1-877-687-1196 (RelayTexas/TTY: 1-800-735-2989).If you believe that Ambetter from Superior HealthPlan has failed to provide these services ordiscriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can filea grievance with: Superior HealthPlan Appeal Department, 2100 South Interstate 35, Ste. 200, Austin, TX78704, 1-877-687-1196 (Relay Texas/TTY: 1-800-735-2989), Fax 1-800-310-0943. You can file agrievance in person or by mail, fax, or email. If you need help filing a grievance, Ambetter from SuperiorHealthPlan is available to help you. You can also file a civil rights complaint with the U.S. Department ofHealth and Human Services, Office for Civil Rights electronically through the Office for Civil RightsComplaint 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 tter.SuperiorHealthPlan.com 1-877-687-1196 (Relay Texas/TTY: 1-800-735-2989)This is a solicitation for insurance. 2017 Celtic Insurance Company. All rights reserved.

29418TX0140006-01AmbetterSU SALUD. NUESTRA PRIORIDAD.Ambetter de Superior HealthPlan brinda solucionesde atención médica de calidad que pueden ayudarlea vivir mejor. Con las opciones de cobertura deAmbetter, es más fácil hacerse cargo de su salud.Su salud es importante para nosotros. Y usted mereceaprovechar al máximo su plan de seguro de salud.Al elegir Ambetter de Superior HealthPlan, usted recibirácobertura de atención médica asequible y de calidad queincluye atención preventiva y servicios de salud completos.Y nuestros planes también le dan acceso a programasvaliosos, herramientas educativas y apoyo. Para que sepueda concentrar en permanecer sano.Nuestro compromiso con usted va más allá del consultoriodel médico. Ambetter de Superior HealthPlan es activoen su comunidad local—porque estamos dedicados aayudarle a llevar una vida plena.Para obtener más información,visite Ambetter.SuperiorHealthPlan.com.Atención médica completaCobertura médica completa que incluyetodos sus Beneficios de salud esenciales.Programa de recompensasGane hasta 250 por año cuando toma medidaspara estar sano.Cobertura de medicamentos recetadosObtenga cobertura para sus recetas médicas.Línea de consejo de enfermería que atiende 24/7Llame y hable con un enfermero titulado las 24horas del día, los 7 días de la semana para hacerpreguntas u obtener consejo médico.Cobertura de la vistaCobertura pediátrica para servicios comopor ejemplo exámenes de los ojos y anteojoscon medida. La cobertura opcional de la vistapara adultos solo se ofrece en algunos planesBalanced Care y Essential Care.Ambetter de Superior HealthPlan es una compañía Autorizada de Planes de Salud en el Mercado de seguro médico de Texasy no discrimina basándose en raza, color, origen nacional, discapacidad, edad, sexo, identidad de género, orientación sexualo estado de salud en la administración del plan, incluso inscripción y determinaciones de beneficios.AMB17-TX-C-00020Esta es una publicidad para la venta de seguros. 2017 Celtic Insurance Company. Todos los derechos reservados.

Programa de recompensasde AmbetterNuestro programa de recompensasle ayuda a ganar recompensas por cuidarse.Simplemente complete actividadessaludables, como su examen debienestar anual con su proveedorde atención primaria (PCP) y gane.recompensas de¡Puede ganarhasta 250por año!Use sus recompensaspara ayudar a pagar por: Pagos de la prima mensual Copagos de médicos* Deducibles Coseguro* Las recompensas de My Health Pays no se puedenusar para copagos de farmacia.¡Gane sus recompensasautomáticamente en su TarjetaPrepagada de My Health Pays Visa !Usted recibirá su tarjeta de My HealthPays en el correo cuando gane suprimera recompensa.Para obtener más informaciónsobre las recompensas devisiteAmbetter.SuperiorHealthPlan.com.Esta tarjeta la emite The Bancorp Bank de acuerdo con una licencia de Visa U.S.A. Inc. The Bancorp Bank; Miembro FDIC. La tarjeta no se puede usar en todos los lugares donde se aceptan tarjetas de débito Visa. Consulte elAcuerdo de Tarjetahabiente para ver las restricciones completas de uso.Controles del idioma inglés. Esta traducción se provee para su conveniencia. Los significados de términos, condiciones y representaciones contenidas en este material están sujetos a definiciones e interpretaciones delidioma inglés. Es posible que la traducción no represente precisamente la información original en inglés.