Anthem Silver Blue Priority/Lean 4100 ($0 Virtual PCP + $0 Select Drugs + Incentives) – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$4,100 per person $4,100 per person
Out-of-pocket max	$7,700 per person $15,400 per family
Metal tier	Silver

Visit Copay

Primary care visit	$35 copay
Specialist visit	25% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$75 copay
Emergency room	$500 copay after deductible, 25% coinsurance after deductible
Ambulance	40% coinsurance after deductible
Hospital stay (facility)	$1000 copay per Stay after deductible, 40% coinsurance after deductible
Hospital stay (physician)	25% coinsurance after deductible
Outpatient procedure (facility)	25% coinsurance after deductible
Outpatient procedure (physician)	25% coinsurance after deductible
Physical rehabilitation	25% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	$1000 copay after deductible, 40% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$5 copay
Brand	25% coinsurance after deductible
Non-preferred Brand	45% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	25% coinsurance after deductible
Imaging (CT/PET/MRI)	$500 copay after deductible, 40% coinsurance after deductible
Blood work	25% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	25% coinsurance after deductible
Psychiatric hospital stay	$1000 copay per Stay after deductible, 40% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://sbc.anthem.com/dpsdeeplink/deepLink/AnthemSilverBluePriorityLean41000VirtualPCP0SelectDrugsIncentives/English/DG166700590540.pdf
Drug and medication plan formulary	https://www.anthem.com/WISelectdrugtier4
Search doctor list	https://www.anthem.com/find-care/?alphaprefix=DHS