Anthem Silver Pathway PCP Copay Choice X 5000($0 Virtual PCP+$0 Select Drugs) – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$5,000 per person $5,000 per person
Out-of-pocket max	$9,450 per person $18,900 per family
Metal tier	Silver

Visit Copay

Primary care visit	$5 copay
Specialist visit	$75 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$75 copay
Emergency room	$750 copay after deductible, 30% coinsurance after deductible
Ambulance	30% coinsurance after deductible
Hospital stay (facility)	30% coinsurance after deductible
Hospital stay (physician)	30% coinsurance after deductible
Outpatient procedure (facility)	30% coinsurance after deductible
Outpatient procedure (physician)	30% coinsurance after deductible
Physical rehabilitation	30% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	30% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$5 copay
Brand	$30 copay
Non-preferred Brand	35% coinsurance after deductible
Specialty	40% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	30% coinsurance after deductible
Imaging (CT/PET/MRI)	$300 copay after deductible, 50% coinsurance after deductible
Blood work	30% coinsurance after deductible

Mental and Psychiatric Health Care

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

Health Plan Provider Information

Health Plan Benefits	https://sbc.anthem.com/dpsdeeplink/deepLink/AnthemSilverPathwayPCPCopayChoiceX50000VirtualPCP0SelectDrugs/English/DG166700543429.pdf
Drug and medication plan formulary	https://www.anthem.com/GASelectdrugtier4
Search doctor list	https://www.anthem.com/find-care/?alphaprefix=Y2W