Anthem Silver Mountain Enhanced HMO 3500 Rx Copay $0 Select Drugs – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: first 3 visit(s) $35 then 15% after deductible copay, first 3 visit(s) $35 then 15% after deductible
Specialist visit: 15% after deductible
Urgent care visit: first 3 visit(s) $75 then $75 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $3,500 per person $3,500 per person |
| Out-of-pocket max | $9,450 per person $18,900 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | first 3 visit(s) $35 then 15% after deductible copay, first 3 visit(s) $35 then 15% after deductible |
| Specialist visit | 15% after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | first 3 visit(s) $75 then $75 copay |
| Emergency room | $500 plus 15% after deductible copay, $500 plus 15% after deductible |
| Ambulance | 15% after deductible |
| Hospital stay (facility) | $500 plus 30% after deductible copay, $500 plus 30% after deductible |
| Hospital stay (physician) | 15% after deductible |
| Outpatient procedure (facility) | 15% after deductible |
| Outpatient procedure (physician) | 15% after deductible |
| Physical rehabilitation | $35 plus 15% after deductible copay, $35 plus 15% after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | $500 plus 30% after deductible copay, $500 plus 30% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $5 copay |
| Brand | $70 copay |
| Non-preferred Brand | $100 copay |
| Specialty | $670 copay |
Lab Tests and Diagnostic Procedures
| X-rays | 15% after deductible |
| Imaging (CT/PET/MRI) | $500 plus 15% after deductible copay, $500 plus 15% after deductible |
| Blood work | 15% after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 15% after deductible |
| Psychiatric hospital stay | $500 plus 30% after deductible copay, $500 plus 30% after deductible |
