Anthem Gold Pathway X Transition HMO 2300 ($0 Virtual PCP + $0 Select Drugs + Incentives) – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$2,300 per person $2,300 per person
Out-of-pocket max	$7,250 per person $14,500 per family
Metal tier	Gold

Visit Copay

Primary care visit	$15 copay
Specialist visit	$50 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$75 copay
Emergency room	$300 copay after deductible, 20% coinsurance after deductible
Ambulance	20% coinsurance after deductible
Hospital stay (facility)	$500 copay per Stay after deductible, 50% coinsurance after deductible
Hospital stay (physician)	20% coinsurance after deductible
Outpatient procedure (facility)	20% coinsurance after deductible
Outpatient procedure (physician)	20% coinsurance after deductible
Physical rehabilitation	$15 copay

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	$500 copay after deductible, 50% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$5 copay
Brand	$35 copay after deductible
Non-preferred Brand	40% coinsurance after deductible
Specialty	40% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	20% coinsurance after deductible
Imaging (CT/PET/MRI)	$300 copay after deductible, 50% coinsurance after deductible
Blood work	20% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$15 copay
Psychiatric hospital stay	$500 copay per Stay after deductible, 50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits

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