Silver PPO Standard Pathway 94% CSR – PPO
94% cost sharing reduction [Popular Plan]
Network type: PPO
Coverage tier: Silver
Primary care visit: $10 copay
Specialist visit: $30 copay
Urgent care visit: $25 copay
Description
This plan has 94% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | PPO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $1,050 per person $2,100 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $10 copay |
| Specialist visit | $30 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $25 copay |
| Emergency room | $50 copay |
| Ambulance | No charge |
| Hospital stay (facility) | first 4 day(s) $75 per day then $0 copay |
| Hospital stay (physician) | No charge |
| Outpatient procedure (facility) | $75 copay |
| Outpatient procedure (physician) | No charge |
| Physical rehabilitation | $20 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | first 4 day(s) $75 per day then $0 copay |
Pharmacy, Drugs, and Medication
| Generic | $5 per script copay |
| Brand | $10 per script copay |
| Non-preferred Brand | $30 per script copay |
| Specialty | 20%, up to $60 per script copay, 20%, up to $60 per script coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | $25 copay |
| Imaging (CT/PET/MRI) | first 7 visit(s) $50 then $0 copay |
| Blood work | $10 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $10 copay |
| Psychiatric hospital stay | first 4 day(s) $75 per day then $0 copay |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/KGBAo9KBt35xmMwvCx5SaN3g.pdf |
| Drug and medication plan formulary | https://www.anthem.com/ms/pharmacyinformation/home.html |
