Anthem Silver Mountain Enhanced HMO 2800 30% $0 Select Drugs – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $10 copay
Specialist visit: 30% after deductible
Urgent care visit: $75 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | See brochure See brochure |
| Out-of-pocket max | N/A per person N/A per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $10 copay |
| Specialist visit | 30% after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay |
| Emergency room | $350 plus 30% after deductible copay, $350 plus 30% after deductible |
| Ambulance | 35% after deductible |
| Hospital stay (facility) | $500 plus 30% after deductible copay, $500 plus 30% after deductible |
| Hospital stay (physician) | 30% after deductible |
| Outpatient procedure (facility) | 30% after deductible |
| Outpatient procedure (physician) | 30% after deductible |
| Physical rehabilitation | $10 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $500 plus 30% after deductible copay, $500 plus 30% after deductible |
Pharmacy, Drugs, and Medication
| Generic | 30% after deductible |
| Brand | 30% after deductible |
| Non-preferred Brand | 30% after deductible |
| Specialty | 30% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 30% after deductible |
| Imaging (CT/PET/MRI) | $250 plus 30% after deductible copay, $250 plus 30% after deductible |
| Blood work | 30% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 30% after deductible |
| Psychiatric hospital stay | $500 plus 30% after deductible copay, $500 plus 30% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/YEmy8Dk9sBag3dv2vn27SaTH.pdf |
