Anthem Gold 1100 $0 Virtual PCP $0 Select Drugs – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: first 2 visit(s) $35 then 25% after deductible copay, first 2 visit(s) $35 then 25% after deductible
Specialist visit: 25% after deductible
Urgent care visit: first 2 visit(s) $50 then $50 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $1,100 per person $1,100 per person |
| Out-of-pocket max | $6,800 per person $13,600 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | first 2 visit(s) $35 then 25% after deductible copay, first 2 visit(s) $35 then 25% after deductible |
| Specialist visit | 25% after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | first 2 visit(s) $50 then $50 copay |
| Emergency room | $500 plus 25% after deductible copay, $500 plus 25% after deductible |
| Ambulance | 25% after deductible |
| Hospital stay (facility) | $1,000 plus 25% after deductible copay, $1,000 plus 25% after deductible |
| Hospital stay (physician) | 25% after deductible |
| Outpatient procedure (facility) | 25% after deductible |
| Outpatient procedure (physician) | 25% after deductible |
| Physical rehabilitation | 25% after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $1,000 plus 25% after deductible copay, $1,000 plus 25% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $10 copay |
| Brand | $40 copay |
| Non-preferred Brand | 30% after deductible |
| Specialty | 30% after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 25% after deductible |
| Imaging (CT/PET/MRI) | $250 plus 25% after deductible copay, $250 plus 25% after deductible |
| Blood work | 25% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 25% after deductible |
| Psychiatric hospital stay | $1,000 plus 25% after deductible copay, $1,000 plus 25% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/QEoTgke1MJMbGx3bRrSpMEY9.pdf |
