Anthem Bronze Pathway X 20% for HSA – EPO

Description

Health Care Plan Details

Network type	EPO
Deductible	$5,500 per person $5,500 per person
Out-of-pocket max	$7,500 per person $15,000 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	20% coinsurance after deductible
Specialist visit	20% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	20% coinsurance after deductible
Emergency room	$500 copay after deductible, 20% coinsurance after deductible
Ambulance	20% coinsurance after deductible
Hospital stay (facility)	$500 copay per Stay after deductible, 20% coinsurance after deductible
Hospital stay (physician)	20% coinsurance after deductible
Outpatient procedure (facility)	20% coinsurance after deductible
Outpatient procedure (physician)	20% coinsurance after deductible
Physical rehabilitation	20% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	$500 copay after deductible, 20% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	20% coinsurance after deductible
Brand	20% coinsurance after deductible
Non-preferred Brand	35% coinsurance after deductible
Specialty	40% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	20% coinsurance after deductible
Imaging (CT/PET/MRI)	$500 copay after deductible, 20% coinsurance after deductible
Blood work	20% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	20% coinsurance after deductible
Psychiatric hospital stay	$500 copay per Stay after deductible, 20% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://sbc.anthem.com/dpsdeeplink/deepLink/AnthemBronzePathwayX20forHSA/English/DG166700590803.pdf
Drug and medication plan formulary	https://www.anthem.com/MOSelectdrugtier4
Search doctor list	https://www.anthem.com/find-care/?alphaprefix=JXK