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70893GA0010001-01AmbetterYOUR HEALTH. OUR PRIORITY.Ambetter from Peach State Health Plan provideshealthcare solutions.Your health is important to us. And you deserve to get themost out of your health insurance plan.By choosing Ambetter from Peach State Health Plan,you’ll receive affordable healthcare coverage thatincludes preventive care and whole health services. Andour plans also give you access to valuable programs,educational tools and support. So you can focus onstaying healthy.Ambetter TelehealthConvenient, 24-hour phone or video access tohealthcare providers for non-emergency healthissues.Medical Care ServicesMedical coverage that includes all of your EssentialHealth Benefits.Rewards ProgramSign up for our rewards program and earn dollarrewards when you take steps to be healthy.Our commitment to you goes beyond the doctor’s office.Ambetter from Peach State Health Plan is active in yourPrescription CoverageGet coverage for your medical prescriptions.local community—because we’re dedicated to helpingyou lead a fulfilling life.To learn more, visit Ambetter.pshpgeorgia.com.24/7 Nurse Advice LineCall and talk to a registered nurse 24 hours a day, 7days a week to ask questions or get medical advice.Vision CoveragePediatric coverage for services such as eye examsand prescription eyewear. Optional adult visioncoverage only offered on some plans.Optional Adult Dental CoverageCoverage for services such as teeth cleanings,screenings and exams. Only offered on some plans.Ambetter from Peach State Health Plan is a Qualified Health Plan issuer in the Georgia Health Insurance Marketplace. Ambetter from Peach State Health Plan complies with applicable Federal civilrights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.This is a solicitation for insurance. 2018 Ambetter of Peach State. All rights reserved.AMB18-GA-C-00032-2

Ambetter Secure Care 1 (2019)with 3 Free PCP Visits (Gold Level)Medical Annual DeductibleIndividual: 1,000; Family: 2,000Medical Coinsurance20% CoinsurancePrescription Drug Annual DeductibleIndividual: 500;Family: 1,000Prescription Drug Coinsurance30% CoinsuranceMaximum Annual Out-of-pocketIndividual: 6,350; Family: 12,700Emergency ServicesYour Cost (In-Network Providers Only)Emergency Room Services 250 Copay after deductibleEmergency Transportation/Ambulance (Air or Ground)Urgent CareCovered benefits are for In-network providers only.To find our most up to date list of in-network providers,please visit our website at Ambetter.pshpgeorgia.com andselect "Find a Provider" in the main menu. Providers listed inthe Ambetter from Peach State Health Plan online directoryare in-network.Out-of-NetworkSubject to Deductible 250 Copay after deductibleYes20% Coinsurance after deductible20% Coinsurance after deductibleYes20% Coinsurance after deductibleNot coveredYesAnnual Well Visit/Screening/Immunization/Well BabyNo chargeNot coveredNoPrimary Care Visit to treat an injury or illness and Maternity20% Coinsurance after deductibleNot coveredYesSpecialist Visit (e.g. Cardiology, Podiatry, Chiropractic Care) 20% Coinsurance after deductibleNot coveredYesImaging (CT/PET Scans, MRIs)20% Coinsurance after deductibleNot coveredYesX-rays & Diagnostic Imaging20% Coinsurance after deductibleNot coveredYesInpatient Facility Fee (Includes Mental Health, SubstanceUse and Maternity)Inpatient Hospital Physician & Surgical Services20% Coinsurance after deductibleNot coveredYes20% Coinsurance after deductibleNot coveredYesOutpatient Facility Fee (e.g. Ambulatory Surgery Center)20% Coinsurance after deductibleNot coveredYesOutpatient Surgery Physician/Surgical Services20% Coinsurance after deductibleNot coveredYesLaboratory Outpatient & Professional Services20% Coinsurance after deductibleNot coveredYes20% Coinsurance after deductibleNot coveredYes20% Coinsurance after deductibleNot coveredYesRoutine Eye Exam (1 visit per year)100% CoveredNot coveredNoEyeglasses (frames, 1 item per year)100% CoveredNot coveredNoLenses (per pair)100% CoveredNot coveredNoGenerics* 10 CopayNot coveredNoPreferred Brand Drugs 25 Copay after prescription drug deductibleNot coveredYesNon-preferred Brand Drugs 75 Copay after prescription drug deductibleNot coveredYesSpecialty Drugs30% Coinsurance after prescription drug deductibleNot coveredYesProvider ServicesInpatient & Outpatient ServicesOther Medical ServicesMental/Behavioral Health & Substance Use DisorderOutpatient ServicesRehabilitation Outpatient Services (includes Speech,Occupational and Physical Therapy)Pediatric VisionPrescription Drugs* 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 comprehensive benefit detail, members should review their Evidence of Coverage andSchedule of Benefits prior to receiving services. Exclusions and limitations may apply.For help understanding the terms used above, see the Health Insurance Terms page on Ambetter.pshpgeorgia.com.Ambetter.pshpgeorgia.com 1-877-687-1180 (TTY/TDD: 1-877-941-9231)This is a solicitation for insurance. 2018 Ambetter of Peach State Inc. All rights reserved.

Statement of Non-DiscriminationAmbetter from Peach State Health Plan complies with applicable Federal civil rights laws and does not discriminateon the basis of race, color, national origin, age, disability, or sex. Ambetter from Peach State Health Plan does notexclude 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 interpretersWritten 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 interpretersInformation written in other languagesIf you need these services, contact Ambetter from Peach State Health Plan at 1-877-687-1180 (TTY/TDD 1-877-9419231).If you believe that Ambetter from Peach State Health Plan has failed to provide these services or discriminated inanother way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Ambetterfrom Peach State Health Plan Complaints Department, 1100 Circle 75 Parkway, Suite 1100, Atlanta, GA 30339, 1877-687-1180 (TTY/TDD 1-877-941-9231), Fax 1-866-532-8855, Email [email protected] You can file agrievance by mail, fax, or email. If you need help filing a grievance, Ambetter from Peach State Health Plan isavailable to help you. You can also file a civil rights complaint with the U.S. Department of Health and HumanServices, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available athttps://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.pshpgeorgia.com 1-877-687-1180 (TTY/TDD: 1-877-941-9231)This is a solicitation for insurance. 2018 Ambetter of Peach State Inc. All rights reserved.AMB18-GA-C-00032-2

70893GA0010001-01AmbetterSU SALUD. NUESTRA PRIORIDAD.Ambetter de Peach State Health Plan brindasoluciones de atención médica.Su salud es importante para nosotros. Y usted se mereceobtener lo máximo de su plan de seguro de salud.Al elegir Ambetter de Peach State Health Plan, recibirácobertura de atención médica al alcance de su bolsilloque incluye atención preventiva y servicios de saludintegrales. Y también, nuestros planes le brindan accesoa valiosos programas, herramientas educativas y apoyo.Para que pueda enfocarse en mantenerse saludable.Nuestro compromiso con usted va más allá delconsultorio médico. En Ambetter de Peach State HealthPlan estamos activos en su comunidad local — porqueestamos dedicados a ayudarle a gozar de una vida plena.Para obtener más información, visiteAmbetter.pshpgeorgia.com.Telesalud de AmbetterConveniente acceso las 24 horas por teléfono ovideo a proveedores de atención médica paratratar asuntos que no son de emergencia.Servicios de atención médicaCobertura médica que incluye todos sus beneficiosde salud esenciales.Programa de recompensasInscríbase en nuestro programa de recompensas ygane recompensas en dólares por tomar medidaspara estar saludable.Cobertura de medicamentos de venta con recetaObtenga cobertura para sus medicamentos deventa con receta médica.Línea de consejo de enfermería que atiende 24/7Llame y hable con personal de enfermeríaregistrado las 24 horas del día, los 7 días de lasemana para hacer preguntas u obtener consejomédico.Cobertura de la vistaCobertura pediátrica para servicios comoexámenes de los ojos y anteojos graduados deventa con receta. La cobertura opcional de la vistapara adultos se ofrece únicamente en algunosplanes.Cobertura dental opcional para adultosCobertura para servicios como exámenes,evaluaciones preventivas y limpieza dentales. Sólose ofrece en algunos planes.Ambetter de Peach State Health Plan es una compañía Autorizada de Planes de Salud en el Mercado de seguro médico de Georgia. Ambetter de Peach State Health Plan cumple con las leyes dederechos civiles federales aplicables y no discrimina basándose en la raza, color, origen nacional, edad, discapacidad, o sexo.Esta es una publicidad para la venta de seguros. 2018 Ambetter ofPeach State. Todos los derechos reservados.AMB18-GA-C-00032-2

Ambetter Secure Care 1 (2019)con 3 visitas al PCP gratuitas (Nivel Oro)Deducible médico anualIndividual: 1,000; Familiar: 2,000Coseguro médicoCoseguro del 20%Deducible anual para medicamentos recetadosIndividual: 500;Familiar: 1,000Coseguro para medicamentos recetadosCoseguro del 30%Máximo anual de su propio bolsilloIndividual: 6,350; Familiar: 12,700Los beneficios cubiertos son solo para proveedoresdentro de la red. Para encontrar nuestra lista másactualizada de proveedores dentro de la red, visite nuestrositio web en Ambetter.pshpgeorgia.com y elija "Encontrar unproveedor" en el menú principal. Los proveedores queaparecen en el directorio en línea de Ambetter de Peach StateHealth Plan están dentro de la red.Servicios de emergenciaSu costo(solo Proveedores dentro de la red)Servicios en la sala de emergenciaCopago de 250 después del deducibleTransporte de emergencia/Ambulancia (aéreo o terrestre)Coseguro del 20% después del deducibleAtención médica de urgenciaCoseguro del 20% después del deducibleNo están cubiertosSíVisita anual de la persona sana/Evaluaciones/Inmunizaciones/Del bebé sanoSin costoNo están cubiertosNoVisita de atención primaria para tratar cualquier lesión o enfermedad ymaternidadVisita al especialista (p. ej., cardiología, podiatría, cuidado quiropráctico)Coseguro del 20% después del deducibleNo están cubiertosSíCoseguro del 20% después del deducibleNo están cubiertosSíObtención de imágenes (CT/PET, MRI)Coseguro del 20% después del deducibleNo están cubiertosSíRadiografías y obtención de imágenes diagnósticasCoseguro del 20% después del deducibleNo están cubiertosSíTarifa en instalaciones para pacientes internados (incluye salud mental,abuso de sustancias y maternidad)Servicios quirúrgicos y de médicos en hospitales como paciente internadoCoseguro del 20% después del deducibleNo están cubiertosSíCoseguro del 20% después del deducibleNo están cubiertosSíTarifas de instituciones para pacientes ambulatorios (p.ej., centro quirúrgicopara pacientes ambulatorios)Médico cirujano/Servicios quirúrgicos para pacientes ambulatoriosCoseguro del 20% después del deducibleNo están cubiertosSíCoseguro del 20% después del deducibleNo están cubiertosSíServicios profesionales y de laboratorio para pacientes ambulatoriosCoseguro del 20% después del deducibleNo están cubiertosSíCoseguro del 20% después del deducibleNo están cubiertosSíCoseguro del 20% después del deducibleNo están cubiertosSíExamen de los ojos de rutina (1 visita por año)Cubierto 100%No están cubiertosNoAnteojos (monturas) (1 artículo por año)Cubierto 100%No están cubiertosNoLentes (por par)Cubierto 100%No están cubiertosNoGenéricos*Copago de 10No están cubiertosNoMedicamentos de marca preferidosCopago de 25 después del deducibleNo están cubiertosSíMedicamentos de marca no preferidosCopago de 75 después del deducibleNo están cubiertosSíMedicamentos especializadosCoseguro del 30% después del deducibleNo están cubiertosSíFuera de la redSujeto adeducibleCopago de 250 después del deducibleSíCoseguro del 20% después del deducibleSíServicios de proveedoresServicios para pacientes internados y ambulatoriosOtros servicios médicosSalud mental/del comportamiento y servicios para pacientes ambulatoriospara trastorno por abuso de sustanciasServicios de rehabilitación para pacientes ambulatorios (incluye terapia delhabla, ocupacional y física)Vista pediátricaMedicamentos recetados* Si el costo del medicamento genérico es menor que el copago, usted paga la menor cantidad.La información que se muestra representa un Plan de costo compartido estándar. Nuestros planes no cubren todos los gastos de atención médica. Los beneficios cubiertos variarán por estado y son solo para proveedores dentro de la red. Para obtener detalles completossobre beneficios, los miembros deberían revisar su Evidencia de cobertura y Lista de beneficios antes de recibir servicios. Puede haber exclusiones y limitaciones.Si necesita ayuda para entender los términos que se usan arriba, consulte la página Términos de seguro médico en Ambetter.pshpgeorgia.com.Ambetter.pshpgeorgia.com 1-877-687-1180 (TTY/TDD: 1-877-941-9231)Esta es una publicidad para la venta de seguros. 2018 Ambetter of Peach State Inc. Todos los derechos reservados.

Declaración de no discriminaciónAmbetter de Peach State Health Plan cumple con las leyes de derechos civiles federales aplicables y no discriminabasándose en la raza, color, origen nacional, edad, discapacidad, o sexo. Ambetter de Peach State Health Plan noexcluye personas o las trata de manera diferente debido a su raza, color, origen nacional, edad, discapacidad, osexo.Ambetter de Peach State Health Plan:Proporciona ayuda y servicios gratuitos a las personas con discapacidad para que se comuniquen eficazmentecon nosotros, tales como:Intérpretes calificados de lenguaje por señasInformación escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, otros formatos)Proporciona servicios de idiomas a las personas cuyo lenguaje primario no es el inglés, tales como:Intérpretes calificadosInformación escrita en otros idiomasSi necesita estos servicios, comuníquese con Ambetter de Peach State Health Plan a 1-877-687-1180 (TTY/TDD 1877-941-9231).Si considera que Ambetter de Peach State Health Plan no le ha proporcionado estos servicios, o en cierto modo le hadiscriminado debido a su raza, color, origen nacional, edad, discapacidad o sexo, puede presentar una queja ante:Ambetter from Peach State Health Plan Complaints Department, 1100 Circle 75 Parkway, Suite 1100, Atlanta, GA30339, 1-877-687-1180 (TTY/TDD 1-877-941-9231), Fax 1-866-532-8855, Email [email protected] Ustedpuede presentar una queja por correo, fax, o correo electrónico. Si necesita ayuda para presentar una queja,Ambetter de Peach State Health Plan está disponible para brindarle ayuda. También puede presentar una queja deviolación a sus derechos civiles ante la Oficina de derechos civiles del Departamento de Salud y Servicios Humanosde Estados Unidos (U.S. Department of Health and Human Services), en forma electrónica a través del portal dequejas de la Oficina de derechos civiles, disponible en https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, o por correo o víatelefónica llamando al: 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).Los formularios de queja están disponibles en tter.pshpgeorgia.com 1-877-687-1180 (TTY/TDD: 1-877-941-9231)Esta es una publicidad para la venta de seguros. 2018 Ambetter of Peach State Inc. Todos los derechos reservados.AMB18-GA-C-00032-2

Ambetter.pshpgeorgia.com 1-877-687-1180 (TTY/TDD: 1-877-941-9231)Esta es una publicidad para la venta de seguros. 2018 Ambetter of Peach State Inc. Todos los derechos reservados.AMB18-GA-C-00032-2

Ambetter Telehealth Convenient, 24-hour phone or video access to healthcare providers for non-emergency health issues. Medical Care Services Medical coverage that includes all of your Essential Health Benefits. Rewards Program Sign up for our rewards program and earn dollar rewards

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