Anthem Silver Pathway X HMO 3500 for HSA ( + Incentives) – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$3,500 per person $3,500 per person
Out-of-pocket max	$7,200 per person $14,400 per family
Metal tier	Silver

Visit Copay

Primary care visit	10% coinsurance after deductible
Specialist visit	10% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	10% coinsurance after deductible
Emergency room	10% coinsurance after deductible
Ambulance	30% coinsurance after deductible
Hospital stay (facility)	30% coinsurance after deductible
Hospital stay (physician)	10% coinsurance after deductible
Outpatient procedure (facility)	10% coinsurance after deductible
Outpatient procedure (physician)	10% coinsurance after deductible
Physical rehabilitation	10% coinsurance after deductible

Maternitowny and Pregnancy

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

Pharmacy, Drugs, and Medication

Generic	10% coinsurance after deductible
Brand	10% coinsurance after deductible
Non-preferred Brand	40% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	10% coinsurance after deductible
Imaging (CT/PET/MRI)	10% coinsurance after deductible
Blood work	10% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	10% coinsurance after deductible
Psychiatric hospital stay	30% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits

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