Anthem Silver Blue Priority/Lean 5300 (3 Free PCP Visits + $0 Select Drugs + Incentives) – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$5,300 per person $5,300 per person
Out-of-pocket max	$9,250 per person $18,500 per family
Metal tier	Silver

Visit Copay

Primary care visit	$30 copay
Specialist visit	$75 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$75 copay
Emergency room	$500 copay after deductible, 35% coinsurance after deductible
Ambulance	50% coinsurance after deductible
Hospital stay (facility)	40% coinsurance after deductible
Hospital stay (physician)	35% coinsurance after deductible
Outpatient procedure (facility)	35% coinsurance after deductible
Outpatient procedure (physician)	35% coinsurance after deductible
Physical rehabilitation	35% coinsurance after deductible

Maternitowny and Pregnancy

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

Pharmacy, Drugs, and Medication

Generic	$15 copay
Brand	$40 copay
Non-preferred Brand	35% coinsurance after deductible
Specialty	40% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	35% coinsurance after deductible
Imaging (CT/PET/MRI)	40% coinsurance after deductible
Blood work	35% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$30 copay
Psychiatric hospital stay	40% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://sbc.anthem.com/dpsdeeplink/deepLink/AnthemSilverBluePriorityLean53003FreePCPVisits0SelectDrugsIncentives/English/DG166700590380.pdf
Drug and medication plan formulary	https://www.anthem.com/WISelectdrugtier4
Search doctor list	https://www.anthem.com/find-care/?alphaprefix=DHS