Anthem Clear Choice Silver Tiered 4200 – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $35 copay
Specialist visit: $80 copay
Urgent care visit: $40 copay
Description
Health Care Plan Details
Network type | HMO |
Deductible | $4,200 per person $4,200 per person |
Out-of-pocket max | $9,100 per person $18,200 per family |
Metal tier | Silver |
Visit Copay
Primary care visit | $35 copay |
Specialist visit | $80 copay |
Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
Urgent care | $40 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 copay |
Maternitowny and Pregnancy
Labor, delivery, hospital stay | 40% after deductible |
Pharmacy, Drugs, and Medication
Generic | $20 copay |
Brand | $50 copay |
Non-preferred Brand | $100 copay after deductible |
Specialty | $250 copay after deductible |
Lab Tests and Diagnostic Procedures
X-rays | 40% after deductible |
Imaging (CT/PET/MRI) | 40% after deductible |
Blood work | $15 copay |
Mental and Psychiatric Health Care
Mental Health outpatient services | $35 copay |
Psychiatric hospital stay | 40% after deductible |
Health Plan Provider Information
Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/7DhwzJV6mxeQuGNXeognEcj9.pdf |