Anthem Silver 3600 for HSA – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$3,600 per person $3,600 per person
Out-of-pocket max	$6,000 per person $12,000 per family
Metal tier	Silver

Visit Copay

Primary care visit	25% after deductible
Specialist visit	25% after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	25% after deductible
Emergency room	50% after deductible
Ambulance	25% after deductible
Hospital stay (facility)	$500 plus 50% after deductible copay, $500 plus 50% 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

$500 plus 50% after deductible copay, $500 plus 50% after deductible

Pharmacy, Drugs, and Medication

Generic	35% after deductible
Brand	35% after deductible
Non-preferred Brand	40% after deductible
Specialty	40% after deductible

Lab Tests and Diagnostic Procedures

X-rays	25% after deductible
Imaging (CT/PET/MRI)	$300 plus 50% after deductible copay, $300 plus 50% after deductible
Blood work	25% after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	25% after deductible
Psychiatric hospital stay	$500 plus 50% after deductible copay, $500 plus 50% after deductible

Health Plan Provider Information

Health Plan Benefits

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