Anthem Silver Pathway X HMO 5000 Adult Dental & Vision ($0 Virtual PCP + $0 Select Drugs) – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$5,000 per person $5,000 per person
Out-of-pocket max	$7,950 per person $15,900 per family
Metal tier	Silver

Visit Copay

Primary care visit	$35 copay
Specialist visit	35% coinsurance after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$50 copay
Emergency room	$500 copay after deductible, 35% coinsurance after deductible
Ambulance	50% coinsurance after deductible
Hospital stay (facility)	$500 copay per Stay after deductible, 50% coinsurance after deductible
Hospital stay (physician)	35% coinsurance after deductible
Outpatient procedure (facility)	35% coinsurance after deductible
Outpatient procedure (physician)	35% coinsurance after deductible
Physical rehabilitation	35% 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	$10 copay
Brand	$40 copay
Non-preferred Brand	40% coinsurance after deductible
Specialty	40% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	35% coinsurance after deductible
Imaging (CT/PET/MRI)	$500 copay after deductible, 50% coinsurance after deductible
Blood work	35% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	35% 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/AnthemSilverPathwayXHMO5000AdultDentalVision0VirtualPCP0SelectDrugs/English/DG166700590289.pdf
Drug and medication plan formulary	https://www.anthem.com/OHSelectdrugtier4
Search doctor list	https://www.anthem.com/find-care/?alphaprefix=JWV