Anthem Silver Pathway X HMO 4500 Adult Dental & Vision ($0 Virtual PCP + $0 Select Rx) – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $30 copay
Specialist visit: $75 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $4,500 per person $4,500 per person |
| Out-of-pocket max | $9,200 per person $18,400 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $30 copay |
| Specialist visit | $75 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $50 copay |
| Emergency room | 20% coinsurance after deductible |
| Ambulance | 20% coinsurance after deductible |
| Hospital stay (facility) | 20% 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 | $30 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 20% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $10 copay |
| Brand | $75 copay |
| Non-preferred Brand | 40% coinsurance after deductible |
| Specialty | 40% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | 20% coinsurance after deductible |
| Imaging (CT/PET/MRI) | No charge after deductible |
| Blood work | 20% coinsurance after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | 20% coinsurance after deductible |
| Psychiatric hospital stay | 20% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/S9QGmj3MnGfRcPQtmUhzmCoh.pdf |
