Anthem Bronze EPO 6300 $0 Virtual PCP $0 Select Drugs – EPO
Network type: EPO
Coverage tier: Bronze
Primary care visit: first 3 visit(s) $60 then $60 copay
Specialist visit: first 3 visit(s) $150 then $150 copay
Urgent care visit: first 3 visit(s) $60 then $60 copay
Description
Health Care Plan Details
| Network type | EPO |
| Deductible | $6,300 per person $6,300 per person |
| Out-of-pocket max | $9,100 per person $18,200 per family |
| Metal tier | Bronze |
Visit Copay
| Primary care visit | first 3 visit(s) $60 then $60 copay |
| Specialist visit | first 3 visit(s) $150 then $150 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | first 3 visit(s) $60 then $60 copay |
| Emergency room | 40% after deductible |
| Ambulance | 40% after deductible |
| Hospital stay (facility) | 40% after deductible |
| Hospital stay (physician) | 40% after deductible |
| Outpatient procedure (facility) | 40% after deductible |
| Outpatient procedure (physician) | 40% after deductible |
| Physical rehabilitation | 40% after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 40% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $30 copay |
| Brand | 30% after deductible |
| Non-preferred Brand | 30% after deductible |
| Specialty | 30% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $70 copay |
| Imaging (CT/PET/MRI) | 40% after deductible |
| Blood work | $25 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | first 3 visit(s) $60 then $60 copay |
| Psychiatric hospital stay | 40% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/DCLQkxYJ1xZ5RED7usRXEw5H.pdf |
| Drug and medication plan formulary | http://www.anthem.com/pharmacyinformation |
