Anthem Gold Blue Value X 3000($0 Virtual Visits + $0 Select Drugs) – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $10 copay
Specialist visit: $55 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $3,000 per person $3,000 per person |
| Out-of-pocket max | $7,100 per person $14,200 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $10 copay |
| Specialist visit | $55 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | 15% coinsurance after deductible |
| Ambulance | 15% coinsurance after deductible |
| Hospital stay (facility) | 15% coinsurance after deductible |
| Hospital stay (physician) | 15% coinsurance after deductible |
| Outpatient procedure (facility) | 15% coinsurance after deductible |
| Outpatient procedure (physician) | 15% coinsurance after deductible |
| Physical rehabilitation | 15% coinsurance after deductible |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 15% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $5 copay |
| Brand | $20 copay |
| Non-preferred Brand | 40% coinsurance after deductible |
| Specialty | 50% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 15% coinsurance after deductible |
| Imaging (CT/PET/MRI) | No charge after deductible |
| Blood work | 15% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 15% coinsurance after deductible |
| Psychiatric hospital stay | 15% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://sbc.anthem.com/dpsdeeplink/deepLink/AnthemGoldBlueValueX30000VirtualVisits0SelectDrugs/English/DG166700544037.pdf |
| Drug and medication plan formulary | https://www.anthem.com/GASelectdrugtier4 |
| Search doctor list | https://www.anthem.com/find-care/?alphaprefix=BYH |
