Anthem Silver Blue Value X 4500($0 Virtual Visits + $0 Select Drugs) – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$4,500 per person $4,500 per person
Out-of-pocket max	$8,800 per person $17,600 per family
Metal tier	Silver

Visit Copay

Primary care visit	$10 copay
Specialist visit	$75 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

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

Maternitowny and Pregnancy

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

Pharmacy, Drugs, and Medication

Generic	$3 copay
Brand	$40 copay
Non-preferred Brand	40% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

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

Mental and Psychiatric Health Care

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

Health Plan Provider Information

Health Plan Benefits	https://sbc.anthem.com/dpsdeeplink/deepLink/AnthemSilverBlueValueX45000VirtualVisits0SelectDrugs/English/DG166700544164.pdf
Drug and medication plan formulary	https://www.anthem.com/GASelectdrugtier4
Search doctor list	https://www.anthem.com/find-care/?alphaprefix=BYH