Anthem Silver Pathway Essentials 4000 HSA – HMO

Network type: HMO
Coverage tier: Silver
Primary care visit: 15% coinsurance after deductible
Specialist visit: 15% coinsurance after deductible
Urgent care visit: 15% coinsurance after deductible

SKU: 17575IN0700062 Categories: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

Description

Health Care Plan Details

Network type HMO
Deductible $4,000 per person $4,000 per person
Out-of-pocket max $5,600 per person $11,200 per family
Metal tier Silver

Visit Copay

Primary care visit 15% coinsurance after deductible
Specialist visit 15% coinsurance after deductible
Preventive care visit No charge

Urgent, Emergency Care, and Hospital Care

Urgent care 15% coinsurance after deductible
Emergency room $300 copay after deductible, 15% coinsurance after deductible
Ambulance 15% coinsurance after deductible
Hospital stay (facility) $500 copay per Stay after deductible, 50% coinsurance after deductible
Hospital stay (physician) 15% coinsurance after deductible
Outpatient procedure (facility) 15% coinsurance after deductible
Outpatient procedure (physician) 15% coinsurance after deductible
Physical rehabilitation 15% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay $500 copay after deductible, 50% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic $10 copay after deductible
Brand $40 copay after deductible
Non-preferred Brand 35% coinsurance after deductible
Specialty 40% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays 15% coinsurance after deductible
Imaging (CT/PET/MRI) $300 copay after deductible, 50% coinsurance after deductible
Blood work 15% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services 15% coinsurance after deductible
Psychiatric hospital stay $500 copay per Stay after deductible, 50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://sbc.anthem.com/dpsdeeplink/deepLink/AnthemSilverPathwayEssentials4000HSA/English/DG166700590552.pdf
Drug and medication plan formulary https://www.anthem.com/INSelectdrugtier4
Search doctor list https://www.anthem.com/find-care/?alphaprefix=E7E