Anthem Silver Blue Priority/Lean 4100 S04 ($0 Virtual PCP + $0 Select Drugs + Incentives) – HMO
73% cost sharing reduction [Popular Plan]
Network type: HMO
Coverage tier: Silver
Primary care visit: $35 copay
Specialist visit: 25% coinsurance after deductible
Urgent care visit: $75 copay
Description
This plan has 73% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | HMO |
| Deductible | $3,700 per person $3,700 per person |
| Out-of-pocket max | $5,900 per person $11,800 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) | $500 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 | $500 copay after deductible, 40% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $3 copay |
| Brand | 25% coinsurance after deductible |
| Non-preferred Brand | 35% coinsurance after deductible |
| Specialty | 40% 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 | $500 copay per Stay after deductible, 40% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://sbc.anthem.com/dpsdeeplink/deepLink/AnthemSilverBluePriorityLean4100S040VirtualPCP0SelectDrugsIncentives/English/DG166700590367.pdf |
| Drug and medication plan formulary | https://www.anthem.com/WISelectdrugtier4 |
| Search doctor list | https://www.anthem.com/find-care/?alphaprefix=DHS |
