Anthem Bronze Pathway X 6500 ($0 Virtual PCP + $0 Select Drugs + Incentives) – EPO

Description

Health Care Plan Details

Network type	EPO
Deductible	$6,500 per person $6,500 per person
Out-of-pocket max	$9,450 per person $18,900 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	$50 copay
Specialist visit	$85 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$75 copay
Emergency room	$500 copay after deductible, 40% coinsurance after deductible
Ambulance	40% coinsurance after deductible
Hospital stay (facility)	$1000 copay per Stay after deductible, 50% coinsurance after deductible
Hospital stay (physician)	40% coinsurance after deductible
Outpatient procedure (facility)	40% coinsurance after deductible
Outpatient procedure (physician)	40% coinsurance after deductible
Physical rehabilitation	$50 copay

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	$1000 copay after deductible, 50% coinsurance after deductible

Pharmacy, Drugs, and Medication

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

Lab Tests and Diagnostic Procedures

X-rays	40% coinsurance after deductible
Imaging (CT/PET/MRI)	$500 copay after deductible, 50% coinsurance after deductible
Blood work	40% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	40% coinsurance after deductible
Psychiatric hospital stay	$1000 copay per Stay after deductible, 50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://sbc.anthem.com/dpsdeeplink/deepLink/AnthemBronzePathwayX65000VirtualPCP0SelectDrugsIncentives/English/DG166700590800.pdf
Drug and medication plan formulary	https://www.anthem.com/MOSelectdrugtier4
Search doctor list	https://www.anthem.com/find-care/?alphaprefix=JXK