Anthem Silver Pathway X 3950 ($0 Virtual PCP + $0 Select Drugs + Incentives) – EPO

Description

Health Care Plan Details

Network type	EPO
Deductible	$3,950 per person $3,950 per person
Out-of-pocket max	$9,400 per person $18,800 per family
Metal tier	Silver

Visit Copay

Primary care visit	$45 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, 20% coinsurance after deductible
Ambulance	20% coinsurance after deductible
Hospital stay (facility)	$500 copay per Stay after deductible, 40% coinsurance after deductible
Hospital stay (physician)	20% coinsurance after deductible
Outpatient procedure (facility)	20% coinsurance after deductible
Outpatient procedure (physician)	20% coinsurance after deductible
Physical rehabilitation	$45 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	$10 copay
Brand	$30 copay
Non-preferred Brand	35% coinsurance after deductible
Specialty	40% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	20% coinsurance after deductible
Imaging (CT/PET/MRI)	$500 copay after deductible, 40% coinsurance after deductible
Blood work	20% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	20% 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/AnthemSilverPathwayX39500VirtualPCP0SelectDrugsIncentives/English/DG166700596583.pdf
Drug and medication plan formulary	https://www.anthem.com/MOSelectdrugtier4
Search doctor list	https://www.anthem.com/find-care/?alphaprefix=JXK