Anthem Gold Pathway X Guided Access HMO 1350($0 Virtual PCP+$0 Select Drugs) – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$1,350 per person $1,350 per person
Out-of-pocket max	$8,800 per person $17,600 per family
Metal tier	Gold

Visit Copay

Primary care visit	$20 copay
Specialist visit	$60 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$50 copay
Emergency room	$750 copay after deductible, 10% coinsurance after deductible
Ambulance	10% coinsurance after deductible
Hospital stay (facility)	$500 copay per Stay after deductible, 45% coinsurance after deductible
Hospital stay (physician)	10% coinsurance after deductible
Outpatient procedure (facility)	10% coinsurance after deductible
Outpatient procedure (physician)	10% coinsurance after deductible
Physical rehabilitation	10% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	$500 copay after deductible, 45% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$10 copay
Brand	$40 copay
Non-preferred Brand	40% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	10% coinsurance after deductible
Imaging (CT/PET/MRI)	$200 copay after deductible, 35% coinsurance after deductible
Blood work	10% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	10% coinsurance after deductible
Psychiatric hospital stay	$500 copay per Stay after deductible, 45% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://sbc.anthem.com/dpsdeeplink/deepLink/AnthemGoldPathwayXGuidedAccessHMO13500VirtualPCP0SelectDrugs/English/DG166700543861.pdf
Drug and medication plan formulary	https://www.anthem.com/GASelectdrugtier4
Search doctor list	https://www.anthem.com/find-care/?alphaprefix=GAP