Gold PPO Pathway – PPO
Network type: PPO
Coverage tier: Gold
Primary care visit: 10% after deductible
Specialist visit: 10% after deductible
Urgent care visit: 10% after deductible
Description
Health Care Plan Details
| Network type | PPO |
| Deductible | $2,000 per person $2,000 per person |
| Out-of-pocket max | $9,000 per person $18,000 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | 10% after deductible |
| Specialist visit | 10% after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | 10% after deductible |
| Emergency room | 10% after deductible |
| Ambulance | 10% after deductible |
| Hospital stay (facility) | 10% after deductible |
| Hospital stay (physician) | 10% after deductible |
| Outpatient procedure (facility) | 10% after deductible |
| Outpatient procedure (physician) | 10% after deductible |
| Physical rehabilitation | 10% after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 10% after deductible |
Pharmacy, Drugs, and Medication
| Generic | 10% coinsurance |
| Brand | 20% coinsurance |
| Non-preferred Brand | 20%, up to $500 per script copay, 20%, up to $500 per script coinsurance |
| Specialty | 20% after deductible, up to $1,000 per script copay, 20% after deductible, up to $1,000 per script |
Lab Tests and Diagnostic Procedures
| X-rays | 10% after deductible |
| Imaging (CT/PET/MRI) | 10% after deductible |
| Blood work | 10% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 10% after deductible |
| Psychiatric hospital stay | 10% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/79y5VSqVsWLEZjBxgtTCfQKr.pdf |
| Drug and medication plan formulary | https://www.anthem.com/ms/pharmacyinformation/home.html |
