Anthem Silver Blue Value X 6500($0 Virtual Visits + $0 Select Drugs) S04 – HMO

Description

This plan has 73% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	HMO
Deductible	$4,400 per person $4,400 per person
Out-of-pocket max	$7,250 per person $14,500 per family
Metal tier	Silver

Visit Copay

Primary care visit	$15 copay
Specialist visit	$75 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$50 copay
Emergency room	$400 copay after deductible, 40% coinsurance after deductible
Ambulance	40% coinsurance after deductible
Hospital stay (facility)	40% coinsurance after deductible
Hospital stay (physician)	40% coinsurance after deductible
Outpatient procedure (facility)	40% coinsurance after deductible
Outpatient procedure (physician)	40% coinsurance after deductible
Physical rehabilitation	40% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	40% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$3 copay
Brand	$35 copay
Non-preferred Brand	35% coinsurance after deductible
Specialty	40% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	40% coinsurance after deductible
Imaging (CT/PET/MRI)	40% coinsurance after deductible
Blood work	40% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	40% coinsurance after deductible
Psychiatric hospital stay	40% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://sbc.anthem.com/dpsdeeplink/deepLink/AnthemSilverBlueValueX65000VirtualVisits0SelectDrugsS04/English/DG166700544194.pdf
Drug and medication plan formulary	https://www.anthem.com/GASelectdrugtier4
Search doctor list	https://www.anthem.com/find-care/?alphaprefix=BYH