Anthem Silver Pathway X HMO 4950($0 Virtual PCP+$0 Select Drugs) – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$4,950 per person $4,950 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	$80 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$75 copay
Emergency room	$750 copay after deductible, 25% coinsurance after deductible
Ambulance	25% coinsurance after deductible
Hospital stay (facility)	$500 copay per Stay after deductible, 50% coinsurance after deductible
Hospital stay (physician)	25% coinsurance after deductible
Outpatient procedure (facility)	25% coinsurance after deductible
Outpatient procedure (physician)	25% coinsurance after deductible
Physical rehabilitation	25% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	$500 copay after deductible, 50% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$3 copay
Brand	$40 copay
Non-preferred Brand	40% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	25% coinsurance after deductible
Imaging (CT/PET/MRI)	$500 copay after deductible, 50% coinsurance after deductible
Blood work	25% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	25% coinsurance after deductible
Psychiatric hospital stay	$500 copay per Stay after deductible, 50% coinsurance after deductible

Health Plan Provider Information

Health Plan Benefits	https://sbc.anthem.com/dpsdeeplink/deepLink/AnthemSilverPathwayXHMO49500VirtualPCP0SelectDrugs/English/DG166700543631.pdf
Drug and medication plan formulary	https://www.anthem.com/GASelectdrugtier4
Search doctor list	https://www.anthem.com/find-care/?alphaprefix=JRA