Anthem Silver Pathway X 2950 ($0 Virtual PCP + $0 Select Drugs + Incentives) – EPO

Network type: EPO
Coverage tier: Silver
Primary care visit: $25 copay
Specialist visit: $75 copay
Urgent care visit: $75 copay

SKU: 32753MO0950002 Categories: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,

Description

Health Care Plan Details

Network type EPO
Deductible $2,950 per person $2,950 per person
Out-of-pocket max $9,450 per person $18,900 per family
Metal tier Silver

Visit Copay

Primary care visit $25 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, 30% coinsurance after deductible
Ambulance 30% coinsurance after deductible
Hospital stay (facility) $500 copay per Stay after deductible, 40% 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 $25 copay

Maternitowny and Pregnancy

Well baby care No charge
Labor, delivery, hospital stay $500 copay after deductible, 40% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic $3 copay
Brand 30% coinsurance after deductible
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) $500 copay after deductible, 40% 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 $500 copay per Stay after deductible, 40% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits https://sbc.anthem.com/dpsdeeplink/deepLink/AnthemSilverPathwayX29500VirtualPCP0SelectDrugsIncentives/English/DG166700590802.pdf
Drug and medication plan formulary https://www.anthem.com/MOSelectdrugtier4
Search doctor list https://www.anthem.com/find-care/?alphaprefix=JXK